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Inspection on 01/09/05 for Charlotte House Mental Nursing Home

Also see our care home review for Charlotte House Mental Nursing Home for more information

This inspection was carried out on 1st September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The activities provision in the home is good and the home employs motivated and committed activities co-ordinators. Staff are provided with regular training updates. The environment is well maintained.

What has improved since the last inspection?

Staff records and recruitment checks have improved since the last inspection.

What the care home could do better:

The home could improve the systems in place to monitor the health and safety maintenance and servicing records in the home to ensure that these are up to date and in order at all times.

CARE HOMES FOR OLDER PEOPLE Charlotte House Mental Nursing Home Snowy Fielder Waye Isleworth Middlesex TW7 6AE Lead Inspector Paula Eaton Unannounced 01 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Charlotte House Mental Nursing Home Address Snowy Fielder Waye, Isleworth, Middlesex TW7 6AE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8758 0080 020 8758 0054 Care UK Community Partnerships Limited Care Home 60 Category(ies) of Mental Disorder - excluding learning disability or registration, with number dementia (0), Mental Disorder - excluding of places learning disability or dementia - over 65 years of age (0), Dementia (0) Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25/01/05 Brief Description of the Service: Charlotte House is a care home providing nursing care to sixty elderly mentally ill people over the age of sixty. It is also registered to provide care to ten people over the age of fifty. The home has fifty two single rooms and four double rooms, these are located on the ground and first floors. All rooms have en suite facilities. There are four units two on each floor. The home is located next to West Middlesex University Hospital and is close to Hounslow High Street. There is a large secure garden to the rear of the building that can be accessed from the ground floor. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours in the afternoon as part of the annual inspection process. The Acting Manager, three staff and six service users were spoken to and records, policies and procedures were examined. What the service does well: What has improved since the last inspection? 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. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The home carries out satisfactory assessments of service users prior to admission to ensure the home is able to meet their needs. EVIDENCE: The home carries out a pre-admission assessment and a more detailed assessment once a service user is admitted to the home. The information contained in the assessment documentation inspected covered all areas of need for each service user. The home had also obtained any Care Management assessments that had been completed. The homes assessment and the Care Management assessments had been used to develop care plans for the service users. All assessments had been carried out by a qualified member of staff. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Assessed needs had been incorporated into individual plans of care although more attention needs to be paid to the social and leisure needs of service users. Health care needs had been assessed and were being met. The systems for administration of medication were satisfactory. Service users were being treated respectfully. EVIDENCE: A comprehensive, detailed care planning system is in place in the home and the majority of the care plans viewed were comprehensive documents that covered all areas of need. However, it was noted that very little attention had been paid to the social and leisure needs of service users and in some cases nothing at all was recorded. It was also noted that not all care plans were being regularly reviewed. Daily records are maintained for each service user and each service user has a named nurse and key worker. Health care needs were outlined in the records examined and were incorporated into the care plans. Any health care appointments attended or treatment received had been recorded clearly. Appropriate assessments are carried out to ascertain service users needs including assessments on nutrition, continence, moving and handling and risk of pressure sores. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 9 The medication store and records for the first floor were viewed. Medication was appropriately stored and the medication administration record sheets were up to date and in order. There were no controlled drugs being used. The home has satisfactory medication policies and procedures in place. Staff were observed treating service users respectfully and the service users spoken to all said that the staff were ‘kind’ and ‘helpful’. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15 The social and leisure needs of service users are met and service users are encouraged to maintain contact with family and friends. The dietary needs of service users are well catered for. EVIDENCE: The Activities Co-ordinators in the home arrange a wide range of activities to meet the individual and group needs of service users. The activities programme is displayed in service users bedrooms and includes activities such as gentle exercise, memory cards, nostalgia, games and music. Group trips out are sometimes arranged and entertainers also visit the home. As discussed earlier it is important individual social and leisure needs are recorded in the care plans for all service users. Visitors are welcomed at the home, service users can see their visitors in private either in their rooms or in the small lounge areas on both floors. There are also areas in the garden where service users can meet with their visitors depending on the weather. Relatives were observed visiting service users during the inspection. The lunchtime meal being served on the day of the inspection was Chicken Korma or Ravioli and Butterscotch Sponge with Custard for pudding. This was not the meal recorded on the menu for that day. The Cook explained that this was because the home had started using a new supplier who had not provided Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 11 the right foods. The home has a four-week menu, the food provided was satisfactory. Specialist diets are catered for as required. The service users spoken to said that they enjoyed the food in the home. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints system with information available to service users, staff and visitors to the home. The home has adequate systems in place for the protection of service users from abuse. EVIDENCE: The home has an appropriate complaints procedure in place that is displayed in the home. Information regarding making a complaint is also provided to all service users and/or their representatives. The complaint record was examined and was satisfactory. The home has satisfactory procedures in place for the protection of service users and clear guidelines for staff regarding the action they should take if they witness or suspect abuse is taking place or if an allegation is made. This information was readily available in the home and followed. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24 and 26 The home was generally clean, safe and comfortable for the people living there. EVIDENCE: The home is very well maintained both internally and externally. There is an ongoing programme of redecoration throughout the home that is undertaken by the handyman. The home maintains a record of maintenance undertaken, however, it was noted during the inspection that action needed to be taken to complete some minor repairs in service users bedrooms. One bedroom had a broken drawer and in another room the bottom of the radiator needed repairing. There is ample communal space in the home for service users. Each unit has a main lounge area and a small room that service users can see visitors in. Each floor has a dining room. There is a pleasant garden area that is well used during the summer months. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 14 The service users bedrooms were generally well maintained except for the minor repairs mentioned earlier. It was evident that service users had been encouraged to personalise their rooms. Screens were available in the double rooms and service users have a lockable drawer in their bedrooms for items they want to lock away. The home was clean and tidy on the day of the inspection. The laundry was satisfactory and appropriate infection control policies and procedures are in place and appropriately displayed throughout the home. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The numbers and skill mix of the staff team was adequate and the recruitment process was satisfactory. Staff training provided was adequate EVIDENCE: The home has a relatively stable staff team. The acting manager said that the home had five staff vacancies, four for carers and one vacancy for a qualified nurse and that there were bank staff available to cover any staff absences to avoid the use of agency staff. The staffing rotas viewed showed satisfactory numbers of staff on duty and the numbers on duty during the inspection were satisfactory to meet the needs of service users. The staff records viewed showed that robust recruitment procedures were in place and all the necessary recruitment checks had taken place. This has improved since the last inspection. The home has a training programme in place and records are maintained so that attendance at training sessions can be monitored. Each member of staff has an individual training record that is kept in the staff office on each floor. These records were not always up to date. Staff had attended recent training sessions on fire safety, dementia and the protection of vulnerable adults. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 Satisfactory management arrangements were in place for the home. The home has appropriate systems in place to ensure the health, safety and welfare of service users and staff are promoted and protected, however these are not always adhered to. EVIDENCE: Since the last inspection the Registered Manager has left and one of the senior nurses who has been at the home for several years is now Acting Manager. The Acting Manager said that she had previously deputised in the absence of the Registered Manager and felt well supported in her new role. Recruitment for a permanent manager was taking place. The health and safety and maintenance and servicing records for the home were viewed. Generally these were in order, however, some information was not up to date. The Landlord’s Gas Safety Certificate was two months out of date. When this was highlighted to the administrative worker for the home an appointment was made for a gas safety inspection to take place the day after Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 17 the inspection and a copy of the new gas safety certificate has been provided to the CSCI since the inspection. The records relating to fire safety were also examined. These were not satisfactory. There was no current fire risk assessment in place for the home and the records regarding fire drills could not be found. These records have since been forwarded to the CSCI but they are not very clear and the fire drill evaluation record had not been completed for all fire drills. The fire alarm call points and emergency lighting were both being checked on a regular basis to ensure they are in good working order. The accident records for the home were satisfactory. Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 2 Charlotte House Mental Nursing Home G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. Standard 7 7 19 19 38 38 Regulation 15(2)(b) 15(1) 23(2)(b) 23(2)(b) 13(4)(a) (c ) 23(4)(a) Requirement Care plans must be regularly reviewed. Care plans must contain details of each service users social and leisure needs. The broken drawer in room 6 on the ground floor must be repaired The radiator in room 4 on the first floor must be repaired. Health and safety servicing checks must be carried out on time. A current fire risk assessment for the home must be in place. Timescale for action 1/11/05 1/11/05 1/11/05 1/11/05 1/11/05 1/11/05 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. Refer to Standard 30 38 Good Practice Recommendations Individual staff training records should be kept up to date. The records for fire drills should clearly state the time and date of the drill, the staff involved and information regarding how the fire drill went. These records should be clear and kept up to date. G61-G10 s10943 Charlotte House v214897 010905 Stage 4.doc Version 1.30 Page 20 Charlotte House Mental Nursing Home Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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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