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Inspection on 01/06/05 for Charlotte Rose House

Also see our care home review for Charlotte Rose House for more information

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

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 home provides a homely atmosphere for residents. The staff know the individual needs of the residents and the relationship between staff and residents is good with staff being kind and courteous. The residents are very happy with the care they receive. "The carers are lovely" was one comment made.

What has improved since the last inspection?

The home is being upgraded on a gradual basis and since the last inspection a bathroom has been improved and there are plans to provide en-suite facilities in three bedrooms. The information available about the home has been brought up to date.

What the care home could do better:

More comprehensive systems need to be in place to ensure that prospective resident`s care needs are known before admission and care plans must detail all the needs of a resident relating to their health, safety and welfare. Recruitment procedures must be more robust to ensure the safety of residents and procedures for the administration of medicines must be followed at all times.Although radiator covers were in place, these do not protect the residents from harm if they fell against them. The responsible individual must ensure that he, or his representative,visits the home on a regular monthly basis and provides a written report to the Commission and the manager; this issue has been on-going since last year.

CARE HOMES FOR OLDER PEOPLE Chaucer House 1 Norwood Road Skegness Lincs PE25 3AD Lead Inspector Sue Daniells Unannounced 1 June 2005 11:00 am 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. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chaucer House Address 1 Norwood Road Skegness Lincs PE25 3AD 01754 762119 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) Lonrush Limited / Andrew & Summers Mrs P D Coulson Care Home PC only 20 Category(ies) of PD Physical disability 1 registration, with number OP Old age 19 of places Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2005 Brief Description of the Service: Chaucer House is a home providing personal care to elderly people over the age of sixty-five. It is situated in the residential outskirts of Skegness within a short car ride of the town centre. Local services within walking distance of the home include hotel-restaurant, post office and shops.The home comprises a detached three-storey building with the accommodation for service users on both ground and first-floor levels. A passenger shaft lift and stair lift has been installed and serves the upper floor. There are fifteen bedrooms, five of which are shared occupancy.The home is registered to provide accommodation for twenty persons, nineteen categorised as old age and one as physically disabled under the age of sixty five.To the front of the premises there is a patio area for sitting out and a small lawned area to the rear. There are no on-site parking facilities for cars although on-street parking is available at the front and side of the home. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on an unannounced basis in June 2005. The inspector was in the home for five hours. Seven residents were residing in the home on that day. Two residents were “case tracked” – a system which looks at the needs of the resident and follows this through by talking to the residents concerned and the staff who deliver the care, as well as observation of care practices. Two members of staff were spoken to and five residents. A sample of regulatory records and policies and procedures were seen and a tour of the premises took place. Seven residents were living in the home on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: More comprehensive systems need to be in place to ensure that prospective resident’s care needs are known before admission and care plans must detail all the needs of a resident relating to their health, safety and welfare. Recruitment procedures must be more robust to ensure the safety of residents and procedures for the administration of medicines must be followed at all times. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 6 Although radiator covers were in place, these do not protect the residents from harm if they fell against them. The responsible individual must ensure that he, or his representative,visits the home on a regular monthly basis and provides a written report to the Commission and the manager; this issue has been on-going since last year. 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. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 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 standard(s) 1and 3. The home does not provide intermediate care and thefore this Standard is not assessed. Comprehensive information is available for prospective residents or their relatives, to make an informed choice about the home. Accurate pre-admission assessments are not being undertaken. EVIDENCE: Since the last inspection, the Statement of Purpose and Service User Guide have been updated. No permanent residents had been admitted since the last inspection, although one person had been admitted twice for respite care in the last six months. Because of the person coming from some distance away, the manager informed the inspector that she had spoken with them over the telephone to assess their needs, prior to the first admission. However, there were no notes made during the conversation to evidence this and the “pre-admission” assessment had been completed on admission. It was also noted that the medical history was different (for the same condition), the second time the person was admitted. Written confirmation of the ability of the home to meet the needs of the prospective resident had been sent. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9 Care plans are comprehensive and reflect the care that is required by the residents. However, evidence was not available to show that all residents, or their representatives, are included in the process. All the residents health needs are met but more care is required by staff when administering medication, to avoid errors and protect residents. EVIDENCE: Two care plans, picked at random, were examined during the inspection plus the care plan for the respite client. The respite’s care plan had not been reviewed on the second admission. The other two were informative and reflected all the care required by the individuals and both had signed the reviews of their plans. However, one of the plans did not evidence that the resident had been involved in the process. One of the residents spoken to about their care plan could distinctly remember discussing it and signing it, as well as the regular reviews; the other could not remember anything about their plan. None of the current residents required treatment from community nurses and both Skegness surgeries were involved with the medical treatment of the Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 10 residents. The manager stated that she had a good rapport with both surgeries. One service user told the inspector that they asked a staff member to fetch the doctor if they felt they needed one and the GP always came. Residents also have access to chiropody, dental and optical services. Polices and procedures are in place for all aspects concerning medication but it was found that one service user stated that sometimes care staff left her medication on a table for her to take unobserved: the second resident stated that staff always watched while they take any medication given. One drug was still in place in the monitored dosage system (MDS) when it had been signed as being given. The home has used the MDS system for dispensing medication for some time. Training has been undertaken by all carers who administer medication. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 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 standard(s) These standards will be examined during the next inspection. EVIDENCE: Chaucer House C53 C04 34355 Chaucer House 230444 010605 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 A copy of the complaints policy and procedure is available in the home and residents know whom to approach if they have a problem. Staff were aware of the procedure to follow if they suspected abuse. EVIDENCE: The home has a complaints policy and procedure, which is available to all residents and a copy is placed in the entrance hall. The service users spoken to stated that they had not had any reason to complain, with one saying “I’ve never had anything to complain about – it’s a wonderful home” and the other “I’m contented here – I’ve never complained about anything”. Both stated that they would approach the manager with any issues that concerned them. The home has a complaints register although there were no complaints logged. The home’s adult abuse policy now reflects the fact that the home must follow the most recent Lincolnshire policy and guidelines from February 2005. Training on the protection of vulnerable adults has taken place for the majority of staff within the last six months, with the two new members attending the next available course. However they have already had an awareness session with the manager during their induction. Chaucer House C53 C04 34355 Chaucer House 230444 010605 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, 24, 25 and 26 On the day of inspection, the home was safe and comfortable with resident’s bedrooms containing their personal possessions. The home was clean and pleasant but radiator guards do not currently protect residents from hot surfaces. EVIDENCE: The home has been going through, and is continuing, with a series of upgrading of rooms over a period of time. At the time of the inspection three rooms had been highlighted for en-suite facilities to be added. Since the last inspection two window frames had been temporarily repaired as a result of a requirement being made. These windows will be replaced later in the year, as the weather gets warmer. The residents were either sitting in the main lounge or the dining room, which is also designated the smoking area. They spoke fondly of the home and said that they were comfortable. The two rooms visited were personalised with resident’s own possessions and memorabilia. Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 14 Radiator guards have been placed over a number of radiators since the last inspection. However, a large plastic mesh has been used which would not protect a resident from burns if they fell against it. Following discussion with the manager and the responsible person’s representative, it was decided that the guards will be changed, although a requirement has been made. A water test for “Legionella” bacteria has been undertaken in the home and was found to be negative. On the day of the inspection, the home was found to be clean and hygienic and there were no malodours. Chaucer House C53 C04 34355 Chaucer House 230444 010605 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) 29 Residents are put at risk through the home’s recruitment practices. EVIDENCE: Personnel files were examined of two new members of staff. It was found that a risk assessment had not been undertaken for one staff member prior to their employment and no photo was present. In the other file, no written references were available, although there was evidence of a telephone request for them, which had not been followed up. Both staff members had been through a Criminal Records Bureau check before their employment commenced. Chaucer House C53 C04 34355 Chaucer House 230444 010605 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) 33, 35, 37 and 38 The home is run in the best interests of the residents, with their financial interests safeguarded. Records are not always up-to-date although the health, safety and welfare of residents and staff is protected. Monthly registered provider reports are not being produced on a regular basis. EVIDENCE: During the last inspection evidence was seen that questionnaires had been distributed and returned by residents, their families, GP’s, community nurses and friends. The manager stated that questionnaires had again been sent to relatives over the previous two weeks but these had, as yet, not been returned. A report was going to be sent to the Commission by the 31st March regarding the quality assurance results but this had not been received. Following the inspection, a short report had been received which showed that “the home is always welcoming and has a good atmosphere. The residents are all very happy with the care they are given. New forms will be sent out within Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 17 the next two months and a report will then be sent to the Commission when the forms are completed” The manager stated that residents, or their relatives, take care of their money themselves; the home does not have any in safe-keeping. It was found that the registered provider of the company was not visiting the home on a regular monthly basis and providing the Commission with a report; this has been an on-going issue since last year. All records in the home are kept securely when not in use and care plans for individuals can be seen by the resident on request. A selection of records to maintain the health, safety and welfare of residents was seen during the inspection; these included services for the hoist and lift, fire equipment and gas safety. These were found to be up-to-date. Chaucer House C53 C04 34355 Chaucer House 230444 010605 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 3 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x 2 x Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 19 Yes 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. Standard 3 Regulation 14.1 (a) (c) Requirement Timescale for action August 31st 2005 2. 7 3. 29 4. 29 5. 9 6. 25 7. 37 A comprehensive assessment must be undertaken for all residents prior to admission, with the input of the resident and/or their representative. 15.1 Care plans must evidence that the service user or their representative are involved in the process. 19.5 (d) All the information as detailed in Schedule Schedule 2 must be obtained for 2 each member of staff, prior to their employment. 13.4 (c) A risk assessment must be completed as discussed with the Manager at the time of inspection. 13.2, 17.1 Staff must follow the homes (a) policies and procedures for the Schedule administration of medicines, in 3 (k) particular the signing of the treatment sheets, and dispensing of medication. 13.4 (c) Radiator covers must be fitted that protect residents from burning themselves if they fall against them. 26.4 (c ) The registered provider must produce monthly reports on the conduct of the home following an unannounced visit. A copy must C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc August 31st 2005 August 31st 2005 August 31st 2005 August 30th 2005 September 30th 2005 July 31st 2005 Chaucer House Version 1.30 Page 20 be sent to the Commission and a copy left at the home. 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 Good Practice Recommendations Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unity House, The Point Weaver Road, off Whisby Road Lincs LN6 3QN 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 Chaucer House C53 C04 34355 Chaucer House 230444 010605 Stage 4.doc Version 1.30 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!