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Inspection on 04/01/06 for Charlotte Straker House

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

This inspection was carried out on 4th January 2006.

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 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 Committee members give consistent and useful help and support to the manager and her staff. Financial management is good and profits are fed back into the home. The manager maintains high standards of care delivery and is an efficient and forward thinking manager. Redecoration and upgrading works are done to a high standard and planned and budgeted for well in advance. The premises are homely, welcoming and pleasant and bedrooms reflect individual choice and lifestyles. Residents enjoy a high degree of autonomy and excellent relationships with the staff. Only five Commission comment cards had been returned, no comments had been made and no concerns raised.

What has improved since the last inspection?

Items identified at the last inspection were all to do with the premises such as the passenger lift flooring. All of these have been resolved.

CARE HOMES FOR OLDER PEOPLE Charlotte Straker House Cookson Close Corbridge Northumberland NE45 5HB Lead Inspector Kathryn Reid Announced Inspection 4th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Charlotte Straker House Address Cookson Close Corbridge Northumberland NE45 5HB 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) 01434-633999 01434 632316 office@charlottestracker.org.uk The Charlotte Straker Project Mrs Sheila Elizabeth Durkin Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Bedrooms 14A, 14B, 18A, 18B, 19 & 20 are not to be used for nursing care due to difficulties with restricted access or stairs. 9th August 2005 Date of last inspection Brief Description of the Service: The home sits on the perimeter of Corbridge village in the Tyne Valley. There is easy access to the shops, churches and other local amenities. The home provides nursing and residential care and the majority of the nursing beds are within a dedicated area. Three of the nursing beds are GP funded and two are specifically for palliative care. Most rooms have en-suite facilities. The communal areas are generous in size and very pleasant. There is an adequate supply of communal assisted bathrooms and toilets. Suitable specialist equipment is in place for any resident who cannot climb the stairs. The home has a large involvement in the local community and there is a strong emphasis on social care and recreational therapy. Occupancy levels are always high and the home has a good reputation within the community. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection commenced at 10am and lasted four hours. The inspector spent time with the manager, Sheila Durkin and met with the new Responsible Individual, Chairman Peter Wood. A brief tour of the premises was carried out and the inspector met with four residents. No visitors or relatives were seen at this visit. Key standards were inspected and completed at this visit and an update was obtained on any previous issues. Twenty-seven residents were present with two of the GP beds occupied and one empty. What the service does well: What has improved since the last inspection? Items identified at the last inspection were all to do with the premises such as the passenger lift flooring. All of these have been resolved. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Prospective residents are provided with information about the home. Their needs are always fully assessed before admission. EVIDENCE: The service user guide was quickly accessible when needed for reference. The admissions procedure remains thorough. A new and comprehensive preadmission assessment document is in use and has been completed to a high standard. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 10 Individual plans of care are in place and standards of record keeping are good. Residents’ health care needs are well understood and met to a high standard. Residents report that they are treated very well and their privacy is respected. EVIDENCE: A completely new format of care planning and case records is being gradually introduced and it was useful to discuss progress so far with the manager. The Standex system provides quick access to well-organised information and entries so far were comprehensive and well documented. The extent and content of care plans was explored and will need to be monitored to ensure that all aspects of care are covered and to avoid an entirely problem orientated approach to record keeping. The management of nutritional problems was explored. Few residents are underweight and all are regularly assessed. Nutritional supplements are used as necessary. A lack of evidence of fortification of normal meals, fully detailed food records in the kitchen and individual food charts was examined. The manager planned to further discuss food records with her staff. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 10 One resident has some mental health problems. These have been well managed by the staff using antecedent charts and with support from a psychologist. Residents are relaxed and appeared very happy and content. Staff clearly approach them with respect and their rights to privacy are well maintained. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are helped and supported to exercise choice and control over their lives. EVIDENCE: Residents enjoy close and supportive relationships with the staff and are empowered to make decisions about their lives and daily routines. The manager has daily dealings with the residents and they are clearly confident in the way she operates the home. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 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 the following standard(s): 16 Residents and relatives can be confident that any complaints will be well handled. EVIDENCE: Two complaints had been received in 2005 and these had been fully documented. The Committee Chairman had assisted with investigations. One complaint had been partly substantiated and both complainants were satisfied with the outcome of investigations. As discussed the storage of any loose letters and documents should be reviewed to avoid loss. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 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 the following standard(s): 19,21,24 and 26 Ongoing upgrading works provides a safe and well-maintained environment. Suitable and sufficient bathing facilities are available. Residents live in very comfortable, personalised bedrooms and the home is very clean and pleasant throughout. EVIDENCE: Other than some dusty ventilation grills the home was very clean and pleasant throughout. Redecoration and upgrading works are well underway and the ground floor corridors have new carpets. Although varied in size and shape residents’ bedrooms are extremely pleasant. Decoration shortfalls identified at the last inspection have been addressed. The laundry was tidy and well organised. There are plans to reinstate opening French Doors from the dining room to the front grounds. This will also provide a safe ‘holding’ room in case of any need to evacuate the building. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Residents’ needs are met by good numbers of staff. Existing staff are well trained but inadequate recruitment procedures and induction records could jeopardize resident safety and staff competence. EVIDENCE: Two of the senior nurses were about to leave to take up posts in the NHS. Their departures had already been filled with a new appointment and some internal re-organisation that promised a fresh approach and improved cohesion within the care team. NVQ training has been progressing well but there is a current problem with a shortage of assessors. Three staff are working towards an NVQ 3 qualification. Problems were identified with the management of recruitment procedures and storage of information. The inspector found that some references and interview records were missing and there was lack of identity and evidence of qualifications and training. Induction records were not available for two new starters. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 and 38 The home’s management team is impressive and achieves good results. Updating of policy and procedural guidance is needed to ensure the home is always operated in the residents’ best interests. Staff are well supervised. Any health and safety issues are promptly addressed. EVIDENCE: The new Chairman and Responsible Individual, Peter Wood, takes a very proactive approach to his involvement at the home and provides good support to the manager. He and the manager are introducing an impressive strategic risk register to ensure that the home is always prepared for any eventuality and minimise risks as much as possible. The manager remains impressive and is clearly popular with staff and residents. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 16 It appears that checks on the home’s electrical installation are well overdue and a suitable contractor has commenced a full audit of the premises. A selection of key policies and procedures including adult protection, whistle blowing, crises management and complaints were inspected. All were found to be out of date, no longer relevant or an accurate reflection on actual procedures and current best practice. The manager had taken over all formal staff supervisions since early 2005 and comprehensive, well-recorded records were seen. She plans to delegate these to her new senior nurses and care assistants in the near future. There are plans to have three new in house fire trainers. Fires safety records were up to date and the manager planned to check and confirm that all staff have attended suitable fire drills. Minor issues identified at the fire safety inspection in July 2005 have been addressed. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 3 3 X X 4 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X X 3 X 2 Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 16(2)(i) Requirement Review the content and management of menus, food records and any individual food charts. Improve the management of recruitment procedures and storage of information. Ensure that evidence of staff induction is available. Review and update the home’s policies and procedures. Provide the Commission with detail of the outcome of the electrical installation survey. Timescale for action 31/01/06 2 3 4 5 OP29 OP30 OP33 OP38 19 18(1)(c) 12(1) 13(4) 28/02/06 28/02/06 30/04/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations Ensure any loose ‘complaints’ are logged and stored safely. Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Charlotte Straker House DS0000000600.V259083.R01.S.doc Version 5.0 Page 20 - 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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