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Inspection on 06/05/08 for Charlotte Rose House

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

This inspection was carried out on 6th May 2008.

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.

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

People who live at the home made positive and complimentary comments as to their satisfaction with the care and accommodation provided. They all knew who was in charge and said they would feel comfortable to raise any concerns they may have. They said they would be listened to and that staff would take action to try and resolve any complaints they raised. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 6The accommodation is clean and tidy and provides a homely place for the people living there. There is a team of staff who are committed to providing a good standard of care and who have regular training opportunities to ensure their knowledge and skills are kept up to date.

What has improved since the last inspection?

Two of the three issues raised in the previous inspection report have been addressed. These related to ensuring that two written references had been obtained for each staff member employed at the home and ensuring care plans contained sufficient information to detail peoples individuals needs and how to meet them.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Charlotte Rose House 1 Norwood Road Skegness Lincs PE25 3AD Lead Inspector Sue Hayward Unannounced Inspection 6th May 2008 09:30 X10029.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 Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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 Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlotte Rose House Address 1 Norwood Road Skegness Lincs PE25 3AD 01754 762119 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) pcoulson@chaucerhouse102.wanadoo.co.uk Lonrush Ltd Mrs P D Coulson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (1) of places Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2007 Brief Description of the Service: Charlotte Rose House formerly known as Chaucer House is a home providing personal care to people who are 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 people who use the service 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, although at present no one shares a bedroom. The home is registered to provide accommodation for twenty people, nineteen older people and one younger physically disabled person. To the front of the premises there is a patio area for sitting out and a small lawn and seating 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. The current fees for the home range from £351 to £402 with additional charges made for hairdressing, chiropody, opticians, magazines and newspapers. Information about the day-to-day operation of the home and fees, as well as a copy of the last inspection report, is available in the main entrance hall of the home. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. Throughout this report the terms ‘we’ and ‘us’ refer to The Commission for Social Care Inspection (CSCI). This was an unannounced visit and it formed part of an inspection, focussing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. It also included obtaining some additional information on the theme of safeguarding, through asking some set questions to the manager, staff and people who use the service. We also looked at whether this service has good procedures and training to ensure people are well protected. We call this ‘safeguarding systems’. The main method used to do this was through a process we call “case tracking”. This includes following the care of a sample of three people through their records and assessing their care. We spoke to four people who use the service and saw the rooms of the three people whose care was being followed as well as two others that have had recent alterations to them. In addition we spoke to a relative who was visiting, three staff members and the administrator. The visit started at 10:00 and lasted 6 hours. It took into account information we already hold on our files, which was used to plan the visit and produce this report. Prior to the visit the manager completed and sent to us a questionnaire. This gave us important information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. Some specific information was included, which enabled us to send out surveys to people before we visited the service. Six surveys were returned five from people who use the service and one from a relative. Their comments are included throughout this report. The manager was not present at the time of the visit however was spoken to at length the following day when the general outcomes of the visit were discussed with her. What the service does well: People who live at the home made positive and complimentary comments as to their satisfaction with the care and accommodation provided. They all knew who was in charge and said they would feel comfortable to raise any concerns they may have. They said they would be listened to and that staff would take action to try and resolve any complaints they raised. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 6 The accommodation is clean and tidy and provides a homely place for the people living there. There is a team of staff who are committed to providing a good standard of care and who have regular training opportunities to ensure their knowledge and skills are kept up to date. 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. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3, standard 6 does not apply (Older People) and 1 and 2 (Adults 18-65). People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are good systems in place to introduce and assess people to ensure their care needs are identified and can be met at the home. EVIDENCE: There is a range of information about the home on display in the entrance hall including its most recent inspection report, a statement of purpose and a guide for people who use the service. It was noticed that some information produced by the service has not yet been up dated to reflect accurately changes to our title, address and contact details, which could be misleading for people who Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 10 use the service. The manager agreed to ensure this was addressed. (See recommendations in relation to standard 37) Staff confirmed anyone who is admitted to the home is given written information about it and it is also discussed with them. Should anyone need it providing in an alternative format such as larger print arrangements would be made to provide it. People commented that they had received sufficient information about the home to help them to decide whether it was the right place for them and comments from questionnaires demonstrated that all had received a contract. One person said that they had originally come for a “holiday and decided to stay”. Another said their relatives had visited the home on their behalf before admission. Staff confirmed, as did people who use the service, that visitors are welcome at the home anytime. Senior staff said they visit people in their homes or hospital prior to their admission to assess whether their needs can be met at the home. The records of the people whose care was being followed on this occasion whether for short or long term care and one who had been admitted within the past twelve months all showed that an assessment of their needs had been made and from this a plan of care drawn up. The file checked of a recently admitted person also demonstrated that information from other professionals had been obtained to assist with the assessment process. The home does not provide and intermediate care service. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 (Older People) and 6, 9, 16, 18 and 19 and 20 (Adults 18-65). People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans have improved and contain more details about care needs and how they are to be met there but insufficient information is contained in them to demonstrate that the Mental Capacity Act has been taken into consideration when developing them. Staff respect people’s privacy and dignity and their health is being well monitored and promoted. The medication arrangements in place are satisfactory and help to ensure the protection of people who use the service. EVIDENCE: Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 12 All three records checked contained care plans identifying people’s needs. People were aware of the records kept about them and a comment made confirmed staff discussed their care plans with them from “time to time”. Records showed that care plans are reviewed on a monthly basis. People made complimentary comments indicating they “usually” or “always” received the care and support they needed and were of the opinion their privacy and dignity was well respected by staff. Staff had a good knowledge of people’s individual needs and contents of the care plans. A staff member gave an example of how they had tried to improve care plans by including more specific details about the way in which a person was supported to take a bath. Records seen confirmed this. Although care plans made some reference to how people who use the service are supported to make decisions, they did not fully reflect how recent legislation about whether people’s capacity and ability to make decisions had been considered. Records did however; show that some staff had had training about the Mental Capacity Act. There is a “key worker” system in place where staff have specific responsibilities for specific people who use the service. A staff member confirmed personal preferences about this are taken into consideration and people who use the service can choose whether a male or female staff member undertakes this role. Records contained information, which demonstrated when other health professionals such as district nurses had visited and showed that the health care of people is well monitored. There is equipment such as heightened toilet seats, wheelchairs and hoists available to assist people who may need this type of support. People who use the service were complimentary about the support and healthcare received, for example “ I can have the doctor whenever I want and I can see him in private if I wish”. A visitor said that staff kept him well informed of any important information about his relative. A staff member was observed for a short while giving out lunchtime medicines and a safe process was followed. There is a system in place where the majority of medicines that can be are pre-dispensed into individual dosages by the local pharmacist. Storage arrangements are satisfactory. A person who uses the services said she had had the option to be responsible for her own medication however chooses not to. There are satisfactory procedures in place about medication administration and a staff member confirmed that the responsibility for the ordering and receipt in and out of the building of medicines is kept to a minimum of people, which contributes towards the operation of a safe system. Discussion with staff and training records checked cpnfimed that staff had training about how to administer medicines safely. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 (Older People) and 12 –15 and 17 (Adults 18-65). People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a range of social, leisure and recreational interests which people have a choice to participate in. They are supported to have contact with family and friends and visitors are made to feel welcome. Meals are well balanced and cater for people’s individual preferences and dietary needs. EVIDENCE: Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 14 People said they were satisfied with the recreational and social opportunities provided. Records also indicated that people who live at the home are consulted about these and care plans include information about people’s preferences in this respect. People were noticed to be able to come and go as they pleased within the home, garden and local community. There is a newsletter and information on display telling people of forthcoming events such as when entertainers are planned to visit and trips out. One person was having a game of cards with a staff member and when asked said he liked to be involved in this “now and again”. Information provided prior to the visit indicated that current people are all of the Christian faith. A Church service was being held in one of the lounges during the visit and staff said these occur monthly. Comments from people who use the service confirmed that they are able to make their own decisions and choices for example one person said “I can make my own bed if I want, but don’t have to if I don’t”. A visitor confirmed he was always made welcome. Comments about the meals were generally positive, indicating people had a choice and their individual preferences catered for. The main meal on the day was nicely presented. Staff also checked whether people had sufficient portion sizes. It was noticed that there is some flexibility about the times meals are served to meet people’s individual needs and preferences. People said that they had a choice of whether they ate their meals in the dining room or in their own bedrooms. The menu is on display and the chef speaks daily to people about the menus. A person who uses the service said that they knew that it was salad on the menu the following day but as she did not like this she had already discussed with the chef that she would have “egg, ham and fried potatoes”. Menus kept are well maintained but do not record specifically the types of vegetables served. The chef agreed to ensure this was done. The service achieved a food hygiene award of excellent or 3 star from East Lindsey District Council on 27th June 2007. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (Older People) and 22 -23 (Adults 18-65). People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by clear policies and procedures, and are able to express their concerns in a responsive atmosphere. However, the recruitment procedure is not sufficiently well implemented to ensure peoples safety. EVIDENCE: The home has a complaints procedure, which tells people how to make a complaint and how it will be handled. However, this does not include the correct contact details for us. People who use the service all said they knew who was in charge and would feel comfortable to raise any issues, felt they would be listened to and knew where to find the information to tell them how to make a complaint if they needed to. Comments from surveys received indicated that all knew how to make a complaint and one said “The manageress or her deputy are always available 24/7”. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 16 No complaints have been received in the past 12 months. A concern was raised with us in relation to a staff members criminal record bureau check (CRB) but the manager has provided satisfactory written confirmation about this. There are satisfactory policies and procedures in place relating to the protection of people who use the service such as expectations about staff members code of conduct, the services own safe guarding adults policy as well as a copy of the most recent Local Authority procedure, a “whistle-blowing” policy and a policy on how to make a referral to the protection of vulnerable adults register if the need arises. People who use the service said they felt safe and were well treated by staff. Most care staff have had safeguarding adults training which is done through an external agency and had a satisfactory knowledge of what action to take if a matter arose although one had not and was not fully aware of the correct reporting procedure. The manager confirmed she was in the process of arranging more training and acknowledged that it needed to be extended to include staff other than care staff that have contact with people who use the service. One staff members file checked showed evidence that a satisfactory protection of vulnerable adults check (POVA) had been obtained prior to employment but the CRB check had not yet been returned. The manager confirmed that there had been occasions when this staff member had worked in an unsupervised capacity, which may potentially pose a risk to people. She said she was now aware this must not happen and had re-arranged the rota to ensure two people were on wakeful night duty until such time as a satisfactory CRB check for the person concerned had been obtained. The administrator confirmed that no money or valuables are currently being held in safe keeping for people who use the service but there are secure facilities to do so if needed. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 (Older People) and 24 and 30 (Adults 18-65). People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service live in a clean, tidy and well-maintained environment that is suitable for their needs and promotes their safety. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 18 EVIDENCE: Five bedrooms were seen on this occasion. The lounge, dining room and a sample of bathrooms and toilets as well as the kitchen and laundry were also checked. All areas were clean, tidy and smelt fresh. People described their rooms as being comfortable and those that wished had been able to make them more homely with some of their own personal belongings. Equipment such as hoists, heightened toilet seats and handrails were in place. Bedrooms are lockable if people who use the service choose to and it is safe for them to do so. The garden is well maintained and tidy and a person living at the home that was sat out in it said she “liked to do this in the good weather”. “It’s a home from home” and “it’s better than the best hotel” were some of the comments people who live at the home used to describe the service. Since the last visit a room has had an en-suite toilet and wash hand basin provided. Toilets have been provided in two other bedrooms although are not a separate facility. A curtain has been erected for privacy. Discussion with a person who uses one of these rooms and a relative confirmed that this met with their satisfaction. The manager said these changes would be incorporated into the information that is given out to people who use the service so that they are kept fully informed and know what to expect. Staff said they have equipment to promote good hygiene, such as gloves, aprons, hand sanitizers and cleaning materials. The manager has confirmed there are policies and procedures in place relating to maintaining a safe environment and a staff member gave a good description of the action she would take if she came across a safety issue concerning the environment. She confirmed that records are kept of any maintenance matters and these are dealt with promptly. The kitchen was clean and tidy and the report of the most recent visit seen by an environmental health officer awarded three stars/excellent rating on 27th June 2007 in relation to food hygiene. There are satisfactory laundry facilities in place. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 (Older People) and 32, 34 and 35 (Adults 18-65). People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of well-trained staff available to meet the needs and wishes of people who use the service, but residents are at risk where safe recruitment procedures are not consistently followed. EVIDENCE: The records of recruitment of three staff members were checked on this occasion. They showed that staff had completed an application form, provided proof of their identity and completed information relating to their health. References had been taken up prior to employment the latter, which was an issue raised at the time of the last inspection. Copies of relevant certificates and qualifications are obtained to confirm their training. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 20 Of the three staff files checked one showed no evidence of a satisfactory criminals record bureau (CRB) check being received although it had been applied for and a satisfactory protection of vulnerable adults (POVA) check was in place. A copy of a CRB obtained by a previous employer was in place however they are not transferable. The manager confirmed that there had been occasions when the person had worked in an unsupervised capacity but was now aware that this must not happen. She had since re-arranged the rota to ensure two people were on wakeful night duty until such time that she had obtained a satisfactory CRB check for the person concerned. (See also comments made in relation to standards 16 –18, complaints and protection). Staff confirmed there is always two staff on duty during the day. At night there is one person on wakeful duty and one who is on call on the premises. Individual records are kept to show any training staff have participated in and discussion with staff on duty confirmed that this had included some staff obtaining a nationally recognised vocational aware in care as well as training in relation to more specific topics such as medication administration, fire training and training about the Mental Capacity Act and its relevance. Staff said that there is training provided to induct them into the work. All care staff are given an employees handbook a copy which was made available and this includes information about policies and procedures such as those concerned with safe guarding adults. Comments from people who use the service indicated that they felt that they received the care they needed from staff and they were well treated. A friendly rapport was noticed between staff and people who use the service. Thos spoken to felt there was sufficient staff on duty to meet their needs. Staff were also of the opinion there was enough staff on duty to provide the care needed. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 22 31, 33 and 35 - 38, (Older People) and 37 and 39 - 42 (Adults 18-65). People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. This service is satisfactorily managed and the systems in place ensure people’s views about the service are sought in order to review and develop it further. However, the lack of visits by a company representative has the potential that the service will not be effectively monitored. The health, safety and welfare of people who use the service are generally well managed. EVIDENCE: There has been no change to management arrangements since the previous visit. People who use the service know who is in charge. Staff said they felt well supported by the manager and communication was good. There are records in place to demonstrate when staff meetings and residents meetings take place although it was noticed that none had occurred since January and July 2007 although the quality assurance policy made reference to them occurring more frequently. However, people who use the service said they felt able to raise matters with the manager and saw her regularly. Staff said they felt supported by the manager and said she was always on-call when not on duty. There are other quality monitoring systems in place such as questionnaires, which are used periodically with people who use the service and their representatives to obtain their views on the quality of care and accommodation provided. Questionnaires were viewed from November and December 2007 and it was noted that comments were positive such as “staff are very pleasant and “we are always made to feel welcome”. Questionnaires did not include any specific questions aimed at obtaining views to monitor how well people thought the service safeguarded their welfare. The manager agreed to address this. Some of the questionnaires including those given to other professionals who have contact were not dated and it was difficult to ascertain how recently these were. There is a range of policies and procedures for staff to refer to relating to health and safety issues such as manual handling, first aid and missing persons. There are also certificates and records kept to show how health and safety matters are monitored. A sample were checked including records kept to demonstrate that weekly checks are made of the fire alarm system and monthly checks of the emergency lighting system. The fire risk assessment of Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 23 the home was reviewed on 28th April 2008 when a number of matters were raised as needing attention. Discussion with the manager confirmed that some had already been addressed but others still needed to be and gave assurances that those outstanding would be completed within a three-month period. Information provided prior to the visit demonstrated that equipment and appliances are satisfactory maintained. Most of the records that are required to be kept by law were in place however there was no evidence of reports of visits from a company representative and discussion with the manager indicated that these had not been occurring on a monthly basis. This may mean the quality of the service is not being monitored effectively. A sample of records were checked such as the fire risk assessment which was reviewed on 28th April 2008 The records of people who live at the home showed that risk assessments had been undertaken in relation to their environment although an instance was noticed where it had been identified that a window restrictor was needed but had not yet been provided. The manager confirmed it had been arranged for this matter to be addressed by 8th May 2008 and would provide written confirmation of this and the other matters discussed. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 X 5 X 6 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 3 37 2 38 2 Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 18 (1) Requirement Timescale for action 31/07/08 2. OP29 19 (11) Training must be provided about safeguarding adults for those staff who have not yet had any. So they know what to do and are able to appropriately protect people from abuse and/or harm. This requirement had a timescale of 26/06/07, which has not been met. However, some progress has been made therefore an additional timescale is set. A thorough recruitment process 30/06/08 must be followed to ensure people who use the service are protected from unnecessary risks. This must include ensuring staff are appropriately supervised who have commenced employment after obtaining a satisfactory protection of vulnerable adults check whilst awaiting a criminal records bureau check. Staff must not be employed prior to a CRB unless there are exceptional circumstances, which put the health, safety and welfare of people who use the service at DS0000034355.V363966.R01.S.doc Version 5.2 Charlotte Rose House Page 26 risk. 3. OP37 26 In order to ensure there is effective monitoring of the service a company representative must visit and provide a report on the conduct of the service on at least a monthly basis. To ensure the safety of people who use the service action must be taken to minimise any risks, which have been identified for example the fitting of window restrictors where this has been identified as a risk to people who use the service. 30/06/08 4. OP38 13(4) 30/06/08 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 OP7 Good Practice Recommendations Care plans should show more explicitly that people’s capacity to make decisions has been considered under the Mental Capacity Act 2005, so the people who use the service can be sure that their rights and wishes will be known and respected. It is recommended that quality-monitoring systems include obtaining views on how well the service manages to safe guard people who use the service. All policies and procedures should be reviewed to ensure that they accurately reflect how the CSCI can be contacted. 2. OP33 3. OP37 Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Charlotte Rose House DS0000034355.V363966.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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