Inspection on 10/03/06 for Charlton

This inspection was carried out on 10th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charlton 24/04/07

Charlton 07/12/06

Charlton 03/08/05

Charlton 31/03/05

Charlton 28/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charlton Station Road Filton South Glos BS34 7BX Lead Inspector Wendy Kirby Unannounced Inspection 10th March 2006 09:30 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 Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Charlton Address Station Road Filton South Glos BS34 7BX 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) 01454 866142 01454 866848 South Gloucestershire Council Mrs Rachel Dawn Brain Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 32 persons aged 65 years and over requiring personal care 3rd August 2005 Date of last inspection Brief Description of the Service: Charlton was purpose built in 1974. It is a two-storey home providing care and accommodation for thirty older people. Day care facilities are also provided for up to six people each day. The home is one of eight that operate as part of South Gloucestershire Councils Community Care Department. The home is located in an established residential area of Filton approximately four miles north of Bristol city centre. It is close to the Avon Ring Road and within easy reach of the motorway system. There are a range of shops, pubs and a church nearby in addition to a variety of shopping complexes including the Mall at Cribbs Causeway and the adjacent leisure complex. Accommodation is provided on both floors in single rooms. There is a passenger lift. Each bedroom has a wash hand basin. The home has a variety of communal areas and activity rooms. There are gardens to the rear of the home. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process. The inspection lasted one day. A number of records were examined and discussed with the manager, along with procedures and practices concerning admissions, care planning, and health and safety issues. Four residents care plans were looked at in detail along with their profiles. The inspector spent time observing the residents in the home throughout the course of the visit and spoke with several at length. Members of staff were observed on duty. Discussions were held with the cook, her assistant and the administrator. The inspector was given a tour of the premises. What the service does well: What has improved since the last inspection? There is better protection for residents now that accurate medication records are maintained. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 6 The home has developed an action plan with timescales to address areas of refurbishment and those areas requiring home improvements. Needs identified include recommendations made following the previous inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 Prospective residents and their families are able to access clear information to enable them to decide whether the home is suited to their needs and are encouraged to visit the home. Pre admission procedures were able to demonstrate that resident’s needs were identified to ensure that the home would be a suitable place for them to live. Trial visits give prospective residents an opportunity to assess the nature of the home. EVIDENCE: Information on the home and the services offered was on display in the entrance to the home to take away. The information was well presented and included a statement of purpose, a user-friendly welcome pack and a copy of the latest inspection report. The content of the welcome pack provided prospective residents with valuable information on the facilities and services available to them within the home. Prospective residents are encouraged to visit the home either for the day or perhaps for lunch dependent on their wishes. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 9 The Inspector looked at four pre-admission assessments, which were completed fully and were informative. The prospective resident, family and carers are involved in the pre-assessment and all information is used to determine the suitability of the placement. Where possible the manager had also obtained comprehensive assessments and care plans from other professionals involved for example, social workers and hospital staff. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 10 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): 7,8,10,11 The service had good systems for meeting and monitoring residents’ health and personal care needs in consultation with residents. Staff have a good awareness of individuals’ needs and treat the residents in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. Plans are being developed with regards to resident’s wishes when dealing with acute illness and making plans for end of life. EVIDENCE: On admission to the home the resident is assessed over a four-week period and an action plan is developed whereby staff are able to identify residents needs and wishes to determine plans of care. A written review of a residents trial stay demonstrated that all parties had agreed to a permanent stay and that the home was suitable and able to meet the persons needs. Four residents’ records were looked at in detail, including preadmission assessments, care plans, personal history profiles and risk assessments. All Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 11 records showed evidence of consistency in assessing, planning, implementing and evaluating the resident’s care. In discussions with the Manager it was evident that one resident had a very limited English vocabulary. Care provision for this had been addressed and an interpreter visits the resident three times a week. The interpreter’s visits enable the resident to express any concerns/requests she may have. Care plans and reviews also take place with the resident and the interpreter, enabling staff to deliver care effectively. The interpreter is also contacted should the resident need to see other health professionals for example her General Practitioner (GP). Risk assessments were in place with detailed information to ensure safe procedures including, manual handling. Health Care needs were well evidenced in the Care Files and included records of the GP visits with residents and the outcomes were also documented. Specialist referrals and visits from other professionals including Chiropractors, Dentists and Opticians were also seen. Personal history profiles on the residents were very useful and contained information about residents childhood, adolescence and adulthood. Medication was not fully inspected on this occasion, however it was noted that following a requirement from the previous inspection, consistency in recording administration of medication was now taking place. Staff were witnessed knocking on residents doors before entering confirming respect for the residents individual privacy and dignity at all times. All rooms have a telephone point from which residents can make and receive calls. Private telephone lines can be installed. A portable pay phone is available and can be moved from room to room. The atmosphere in the home on the day of the inspection was relaxed. Staff, the manager and residents were observed to have good relationships. Staff responded to residents in a sensitive and professional manner. The manager and her staff have continued to make every effort to establish resident’s wishes concerning palliative care and arrangements for after death. The inspector read a letter the home has devised to encourage and support families in addressing such issues and in most cases this has been welcomed however there are some that have remained undecided. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 12 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): 13,14,15 Residents maintain family contact and staff encourage family and friends to join in with activities and any outings. Residents are able to influence choice and control over their lives. Residents receive a varied and wholesome diet that they are able to influence. EVIDENCE: Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 13 The home operates an open door policy for visitors. Residents are able to see visitors in the privacy of their rooms and there are several semi-private seating areas around the home. Families and friends are also welcome to stay for lunch or tea to assist them with their visiting schedules. The home has a monthly residents meeting which are well attended and minutes are taken and circulated to residents and their families and are displayed on the notice boards throughout the home. Evidence was provided to show topics discussed at the meetings including forthcoming events, any planned refurbishment, and changes in the menu plans. One resident spoken with told the inspector that she had requested additional handrails in the corridor at the last meeting and this had been done. The inspector spent time a short time with the cook and her assistant. The cook was able to demonstrate an awareness of individual requirements and needs of the residents, including special diets and personal preferences. The 4-week menu rota displayed traditional meals and choice was available at each seating. The menus are reviewed to reflect seasonal trends and availability of produce. Residents are able to influence the menus by discussing them at residents’ meetings. Extras are ordered on request for birthdays and special occasions. Documentation was provided to show the inspector that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked before serving. Risk assessments were in place and up to date. The kitchen was very clean and spacious. Stores exhibited a good range of foods. Food hygiene training was not up to date for staff. The size and layout of the dining room made it possible for all residents to enjoy the social advantages of dining together. Staff had used their expertise and knowledge of the residents, personalities, preferences and ability to eat independently, when seating them for lunch. The dining room was light, spacious and the tables were attractively laid with tablecloths. Residents that required assistance with eating their meals were supported by staff members, this was performed in a respectful, sensitive way, for example without rushing the residents and staff were sat at the same level as the resident. Staff were seen to be polite and helpful when serving the meals Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 14 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 There are robust and comprehensive policies in place to manage complaints or allegations of abuse. EVIDENCE: A copy of the complaints procedure is on display in a well-frequented part of the home, which means people will know how to obtain the required information if they want to make a complaint. The information is also provided in the Statement of Purpose and Service User Guide. The complaints policy and procedure is detailed and contains all the required information. Two books are also available in reception enabling residents and visitors to record compliments or concerns they may have. Two complaints had been received since the previous inspection, which were well documented with comprehensive notes, although the outcome information was a little sketchy and did not hold enough detail. Both complaints had been dealt with efficiently and effectively Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 15 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): 19,20,21,23,24,25,26 The home is clean, comfortable, well decorated and furnished. It provides a safe, peaceful and a well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. EVIDENCE: Charlton is purpose built with accommodation on two levels with lift access. The home is fully accessible to residents and is also wheelchair accessible. The courtyard garden was attractive and designed to the needs of the residents. The courtyard has a raised fishpond and planted tubs. There is a summerhouse and pergola and additional outside seating and tables. To the side of the patio there is a lawn area with further seating and planting. The residents spoken with were very complimentary about the home and the garden areas. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 16 The inspector was shown an action plan with dates for refurbishment and improvements for various areas in the home and witnessed the maintenance man decorating. The dining room had been repainted and new flooring was being fitted that week. Resident’s rooms had also been redecorated and they are consulted and involved with choosing colours for their walls and carpets. One carpet in a residents room had a hole in it through wear and tear, which was pointed out to the manager who immediately made arrangements for the carpet to be replaced the same day as the dining room carpet was being fitted. Room sizes are generally adequate for their stated purposes, particularly the lounges and dining room. Bedrooms are not en suite, however each resident has an individual commode and vanity unit with basin. Communal bathing areas, showers and toilet facilities are located throughout the home. All areas of the home were brightly decorated, clean and well maintained. Attention has been given to ensure that all areas are homely. Residents had been supported to personalise their bedrooms with pictures and ornaments and residents are able to bring items of furniture should they wish. One resident spoken with, expressed how she enjoyed looking after a variety of potted plants in her room. Residents were making full use of these areas and their bedrooms on the day of the inspection. The home was clean and free from unpleasant odours. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 17 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): 29,30 Residents are supported and protected by the home’s recruitment policy. Residents and visitors would be better protected if Food Hygiene training was up to date EVIDENCE: A robust recruitment policy and procedure is in place and the staff files inspected showed that all the appropriate documents and checks were in place. Enhanced CRB disclosures are sought for all staff and are only destroyed once an Inspector has seen them. The inspector spent some time throughout the day sitting in the communal areas observing staff carrying out their duties and assisting residents. Staff were respectful, warm in manner, good humoured and sensitive towards the residents within a relaxed, calm environment. The inspector spoke to several residents who expressed very positive views about staff and the care they receive providing comments like, “I am so lucky to be here” and “I am well looked after” Staff training was not inspected on this occasion, however as mentioned previously in the report, Food Hygiene training was not up to date. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 18 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): 31,38 Residents’ needs and best interests are central to the management approach in the home. The health and safety of residents, staff, and visitors is protected. EVIDENCE: The home continues to consistently demonstrate good, effective leadership and management that relates to the aims and purpose of the home. The inspector spent time in discussion with the manager and two senior members of her staff. It was evident in conversations that all three were dynamic in their roles and enjoying the new challenges that faced them. They Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 19 shared various initiatives with the inspector to further develop standards and procedures in the home. The overall outcome was that this fairly newly established management team and their staff were forging together in unison in order to provide a home with high standards for the benefit of all residents, visitors and staff. Some of the Health and safety records in the home were examined. Documentation showed that all relevant checks were maintained correctly and at the required intervals including all fire alarms, equipment and emergency lighting. Fire safety training for staff is given on induction and then at the recommended given intervals. Following each drill staff have a short discussion on the effectiveness of the drill. The provider is completing monthly visits and copies of the reports are being sent to the Commission for Social Care Inspection. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 20 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 21 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 OP30 Regulation 18 (1) (c) Requirement Ensure staff receive training in Food Hygiene. Timescale for action 05/05/06 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. 2. Refer to Standard OP11 OP16 Good Practice Recommendations Staff should continue to obtain the wishes of residents in respect of their end of life wishes. The details of the outcomes following a complaint could contain more information. Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Charlton DS0000035466.V278019.R01.S.doc Version 5.1 Page 23 - 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. 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