Inspection on 03/08/05 for Charlton

This inspection was carried out on 3rd August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Charlton 24/04/07

Charlton 07/12/06

Charlton 10/03/06

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 Michael Miles Unannounced 3 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Charlton Address Station Road Filton South Glos BS34 7BX 01454 866142 01454 866848 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) South Gloucestershire Council Mrs Rachel Dawn Brain PC Care Home 30 Category(ies) of OP Old age (30) registration, with number of places Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 32 persons aged 65 years and over requiring personal care Date of last inspection 31-Mar-2005 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 Council’s 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 is 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 D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 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 that took six hours to complete. There have been no additional visits since the last inspection. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of service users as required. In addition the responsible individual has arranged for the Commission to receive monthly reports of the conduct of the home as required. As part of the inspection the Inspector spoke with service users informally in communal areas and to some more formally in their rooms. In addition the Manager and Deputy Manager were consulted as were a small number of staff. Policies and procedures were examined along with the home’s Mission Statement. Records relating to residents, staff and the processes for management of the home were reviewed. The Commission for Social Care Inspection has produced a leaflet entitled ‘Is the care you get the care you need’ and the Inspector left several copies of these at the home for display. The Inspector would like to thank the staff and residents that participated in the inspection for their welcome and assistance during the process. What the service does well: The Mission statement for the home states ‘Charlton is the residents’ home and staff will respect the privacy, dignity and individuality of each resident’. Residents consulted as part of the inspection made favourable comments about the home complimenting the staff, one describing them as “wonderful” and praising the food. One person stated “the food is beautiful, the home is cleaned everyday and there is always a good supply of water available to drink. I’m quite happy here its wonderful”. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 6 The arrangements for the recruitment, induction, training and supervision of staff ensure that the residents’ are cared for by staff that are informed and supported. The policies and procedures in place ensure that there are sound practices for the protection of residents and staff. Identification of maintenance issues and upgrading of the environment ensures that the home will continue to be a pleasant place in which to live. What has improved since the last inspection? What they could do better: There would be better protection for residents if accurate medication records are maintained at all times. Residents wishes would be more likely fulfilled if staff obtain the wishes of residents in respect of their end of life wishes for those that they have been unable to do as yet. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 7 If the resident identified as vulnerable during the inspection is referred to the appropriate care management team for assessment and support the vulnerability of the person may be minimised. All residents will have the opportunity to use electrical items for entertainment and comfort in their rooms more safely if their room is fitted with at least two accessible double sockets. There would be better temperature control and a safer environment for residents if thermostatic controls are fitted to all radiators. The implementation of a laundry system that minimises the risk of contamination would offer greater protection to residents and staff. Further consideration could be given to the installation of a mechanical bedpan disinfector to assist with infection control. 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 D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Admissions are generally well planned with information and visits available to enable prospective residents to make a positive choice about moving into the home. Their residence in the home is based on contractual terms and conditions that include the fees to be paid. EVIDENCE: One of the residents consulted as part of the inspection confirmed that prior to admission she had been given information about the home and had spent time there to help her to decide if she would move in. Each of the residents files examined had evidence of assessment and review of their care plan. The Manager explained that when there is a major change in a person’s care needs the care plan is rewritten to provide detail to staff. Statements of terms and conditions were in place that included details of fees and how these were broken down. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 10 One of the residents is not English-speaking and the home uses an interpreter on a regular basis. The person was used to explain the contract to the resident and consult the service user about other matters such as food choices. There is regular dialogue between the staff and interpreter to ensure that the resident’s needs are being met. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The health of residents, including administration of medication, is recorded in care plans and is generally well managed however, the home fails to maintain accurate records of medication administered and details of the end of life wishes for all residents. EVIDENCE: As previously mentioned Care Plans are devised based on assessment of need. These are reviewed and there are day and night reports completed by Care Staff. Care Plans are supported by risk assessments related to administration of medication, one to one working, mobility and manual handling. It was noted in files that were examined that the home maintains a log of health related appointments along with weight records. Residents are weighed on a regular basis and to assist with this there is a weighing ‘chair’ in one of the bathrooms. The resident, whose first language is not English, has support to attend medical appointments from the Interpreter. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 12 Medication is administered to residents from a trolley that is kept locked when not in use for safe keeping of drugs. Temazepam is stored as required for the storage of controlled drugs in a locked facility within the lockable wall mounted cupboard that is used to store stocks of medication not currently in use. Medication required to be kept in a refrigerator such as eye drops is and the temperature of the fridge is checked and recorded on a regular basis. A monitored dosage system is used for the administration of most medication and supplies are received from the dispensing Pharmacist on a weekly basis when they are checked and a record of this is maintained. The cassettes are disposable and any unused medication is returned to the Pharmacist and there is a system in place for the Pharmacist’s representative and staff to sign for the return. Profiles of medication are provided by the Pharmacist and the home has information leaflets detailing why medication has been prescribed along with potential side effects. Medication records are maintained, however on some occasions there is no signature for when medication has been administered. The manager advised that this has been addressed with a member of staff and is the subject of ongoing monitoring. In addition, there is no consistency in the recording for medication that has been prescribed for when needed, leaving the record muddled. There is discrete storage of continence management products in lidded baskets in toilet areas. As the home does not have en-suite facilities many of the residents use commodes in their room. At the last inspection the Inspector noted that these are carried through the home, emptied into the sluice and washed by hand. At that time the Manager indicated that consideration was being given to the installation of a mechanical bedpan disinfector. This has not yet taken place. It is recommended that further consideration be given to the installation of a suitable facility.The Inspector did note that there are lids fitted to the commode pans before they are carried through the building. A hairdresser visits the home on a weekly basis to provide a service to residents and there is a designated room for this. At the last inspection it was recommended that the home should establish residents wishes concerning terminal care and arrangements for after death. The home has obtained this information in respect of most residents however there are some that remain undecided or have not been discussed. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 Residents are to make choices regarding food and a range of recreational and educational opportunities, enabled to maintain contact with family and friends and to use the local community. EVIDENCE: There is a snooker table, skittles game and darts board in the games room, along with a selection of board games. There is a visiting library service that includes the provision of ‘talking books’ designed for the visually impaired. It was noted that there was a video collection in one of the lounges providing alternative entertainment for the residents. The gardening group meets in a room on the first floor where craft activities, beauty care, reminiscence and crosswords are completed. It was noted that a member of staff had transferred a crossword on to a large sheet of paper for communal activity. Residents are encouraged to go out and some accompany a staff member on the daily shop for residents from the local shops. Trips are arranged and there was a display of photographs taken at a recent pub outing and a trip has been arranged for a meal at a fish and chip restaurant. One of the residents recently returned from a holiday in Wales with relatives. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 14 The mission statement for the home states that all visitors are made welcome and encouraged to visit at any time. The Deputy Manager advised that some residents have good family support and residents consulted as part of the inspection confirmed that visitors are made welcome. This was further evidenced by the facilities available for residents and their visitors. The Interpreter engaged to work with one of the residents visits the home three times each week and during one of the visits takes the person to church. The mission statement for the home states that residents’ meetings will be held on a regular basis to ensure that residents can voice their own opinions and have a say in how the home is run. It was noted that the most recent of these took place in June 2005. The record of the meeting showed that items discussed were trips, activities, fundraising, the menu, maintenance of the home and the shop. In addition an explanation was given to residents of the need to keep doors closed at night for fire safety. The home has a pet budgerigar that is well cared for and was noted to have a clean cage, in one of the lounges. A shop operates in the home twice each day at 11.30 am and again at 8.30 pm selling a variety of items. There was a selection of sweets, toiletries, gift items, clothing and greetings cards and residents are able to purchase both alcohol and soft drinks. The public telephone is situated within the shop. A clothes supplier will be visiting the home in the near future to enable residents to make purchases. There was a recent barbecue and one resident recently celebrated her 100th birthday, there was evidence of the festivities held in the home including commemorative photographs of the person. The Deputy Manager stated that there are choices at mealtimes and one of the residents chooses a full cooked breakfast every day. The midday meal served on the day of the inspection was roasted chicken with vegetables and seasoning and an alternative was ham. The sweet was fruit with ice cream. The main choice for the evening meal was salad with ham pie followed by cake, fresh fruit or yoghurt. The menu was not examined to check that it was varied and well-balanced and this will be a focus of the next inspection. One of the residents spoke of the arrangements for supper that always includes a selection of sandwiches and biscuits. In the past a questionnaire has been used to gain the opinions of residents regarding food choices and more recently this has been a topic for discussion at a residents meeting. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 There are systems in place for the protection of residents from abuse, who know to whom they should complain and are confident that their complaints will be dealt with. EVIDENCE: Residents have right of redress through the Council’s Complaints process and are supplied with a personal copy of the Home’s complaints leaflet. The home’s leaflet outlines how complaints will be responded to and gives details of the National Care Standards Commission address and telephone number. The Inspector pointed out that the new organisation is called the Commission for Social Care Inspection and the leaflet should be amended to reflect this detail. There are two books kept in the entrance to the home entitled ‘Complaints’ and ‘Compliments’. There were no complaints recorded however there were compliments such as “My husband was a guest here for twelve days. He says he was shown great kindness and was well looked after, nothing was too much trouble”. Another person who had stayed in the home and who the Deputy Manager advised the Inspector had sent flowers to thank staff wrote “Thank you for looking after me”. Records evidenced that the home has provided ‘protection of vulnerable adults’ (POVA) training for all staff as part of the ‘core’ training undertaken during the induction process. A staff member consulted as part of the inspection confirmed she had attended the training and it was noted that refresher training has been identified on the training plan. There was evidence in the record of a recent staff meeting that POVA was discussed at the meeting. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 16 The home responded appropriately to an issue that raised concerns and notified the Commission for Social Care Inspection accordingly. There was discussion at the inspection about the vulnerability of one resident and it was recommended that the person be referred to the appropriate care team for support. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The home is suitable for its purpose, clean and generally well kept. Ongoing maintenance and refurbishment needs are identified and addressed however, there could be improvements to minimise the risk of infection. EVIDENCE: Entrance into the home is through a protected door with a speaker system. Visitors are asked to explain who they are before being allowed in. The administrator’s office is immediately inside the home’s entrance and the manager’s office is a short distance away. There are two lounges each furnished in a homely way. It was noted that there were fresh flowers along with pictures and ornaments. There is a large dining room adjacent to the kitchen. The kitchen was not inspected on this occasion. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 18 There are resident’s bedrooms on each level with bathroom and toilet facilities appropriately located throughout the home. All residents’ rooms seen as part of the inspection were comfortably furnished. It was noted that a shower that had not been used has been re-installed for the comfort of one resident. On the first floor there is an area designated for activities with a games room and multi-function room where craft activities take place and where the gardening group meet. In addition, there is a lounge with television and a kitchen available for use by the residents and their visitors. The bathroom in this area was in the process of re-decoration by the home’s handy-person. There are two additional bedrooms on the first floor that have been refurbished each with two double electrical sockets and a call bell system. These are furnished and will be put in to use once the Council has made an application to vary the conditions of registration of the home and the Commission has agreed the variation. The occupants of the rooms will have the benefit of being able to use the newly refurbished kitchen in this area of the home and they will be able to entertain guests in the small dining room or lounge. Whilst the additional rooms have two double electrical sockets most other rooms do not and this is included in the homes business refurbishment plan. It is particularly relevant that this is addressed as many of the residents now have several items of electrical entertainment equipment in their rooms and recently due to the very warm weather some have purchased electric fans for their personal use. The deputy manager explained that to overcome the shortage of sockets extension leads have been used however, the home has to ensure that trailing wires do not pose a risk. A previous recommendation to have thermostatic controls fitted to all radiators is also on the plan as is the need to have fail safe devices to control hot water at washbasins and baths. There is a bathroom with shower facility that is listed on the home’s refurbishment plan. The stool in the shower area is in need of replacing as the plastic coating has peeled to expose metal that has rusted. In addition the floor of the shower was in need of thorough cleaning. From the dining room there are glass doors that lead onto a patio area. The patio 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. At the time of the inspection there were decorators at the home tending the external paintwork, as previously recommended. Already the look of the home has been given a ‘lift’ and when the scaffolding is removed the full effect will be noticeable. As part of this window restrictors are being serviced to ensure that they are effective. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 19 Laundry facilities are located in a designated area of the home. An additional washing machine has been purchased to enhance the service provided to residents. The facilities include an area for the sorting of personal laundry into containers so that it can be returned safely to residents. At the last inspection the laundering systems of the home were discussed. Staff indicated that heavily soiled linen is first rinsed by Care Staff before being placed inn the washing machine. The Inspector noted that bags for heavily soiled linen are not used as recommended by many infection control specialists. There was discussion regarding this again at this inspection and the Manager advised that only that day she had been informed of a supplier of such bags. It is recommended that a system is utilised to minimise the contamination risk. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 There are sufficient well-motivated and trained staff to meet the needs of residents, that are recruited in a way that ensures protection for the residents. EVIDENCE: The staffing for the home is calculated using the guidance issued by the ‘Residential Forum’ and endorsed by the Department of Health. Residents’ needs are assessed at three levels of dependency and the number of hours calculated to meet these changing needs. There is consideration of the need for specific time for social and recreational activity built into the calculation. Each day there are a minimum of three care staff with housekeeping support staff and at least one manager on duty and at night there are two ‘waking’ night staff. On weekdays there is an additional care assistant deployed for the morning shift. Staff records are now maintained in the home. A sample of these was reviewed and it was noted that they contain the staff member’s application form, references, evidence of their identity and CRB (Criminal Records Bureau) disclosure. There has been some difficulty recruiting domestic staff, however, during the morning of the inspection, there were four staff on duty to clean the home and help with kitchen duties. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 21 Full staff meetings are held twice yearly and there are staff group meetings i.e. Care Staff, Domestics and Cooks meetings every three months. All staff working for the Council’s Community Care Department are subject to annual appraisal as part of the Personal Development and Performance Review. Documents in respect of this was seen in staff files. There are arrangements in place for the supervision of staff with clear accountabilities for this. The Manager has supervision meetings with the Team Manager, and in turn supervises the Deputy and Assistant Managers who share the supervision of other staff in the home. In the past there have been lapses in supervision taking place however, since returning from extended leave, the manager has introduced a system to address this. Supervision is based on agreement between the staff member and their supervisor and there is an individual log maintained of when supervision has taken place as well as a record of the meeting. There is a room on the first floor of the home that has been assigned for staff supervision and for those enrolled for NVQ (National Vocational Qualification) courses to study in. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37,38 The home is well-managed with good supervision of staff that leads to the maintenance of the health and safety of residents and staff. EVIDENCE: A certificate of registration was displayed in the entrance to the home, however it was noted that the details were out of date and during the inspection a certificate detailing the correct information was obtained. The manager has returned from extended leave on a part-time basis and is to job-share the post. There are arrangements being made to fill the vacant hours. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 23 There is a Health and Safety Manual containing information for staff related to a wealth of topics including COSHH (Control of Substances Hazardous to Health) and portable appliance testing (PAT) for electrical appliances. There was an appropriate response to the internal health and safety inspection conducted in October 2004 and a more recent inspection was conducted in March 2005. At the last inspection a requirement was made that all staff should undertake fire training. The Deputy Manager advised that this related to a particular member of night staff who was unable to attend training because of shift patterns. Fire safety has been discussed in supervision with the person and the day of the week for the next session that is due to take place in August has been changed to enable the person to attend. Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 2 3 Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 9 Regulation 13.-(2) 17.-(1)(a) Requirement Accurate medication records must be maintianed at all times. Timescale for action 3.8.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 11 18 Good Practice Recommendations Staff should continue to obtain the wishes of residents in respect of their end of life wishes. It is recommended that the resident identified as vulnerable during the inspection is referred to the appropriate care management team for assessment and support. It is recommended that residents are provided with at least two accessible double sockets in their room. Thermostatic controls should be fitted to all radiators. It is recommended that a laundering system is utilised to minimise the risk of contamination from soiled linen. It is recommended that further consideration be given to the installation of a mechanical bedpan disinfector. 3. 4. 5. 6. 24 25 26 26 Charlton D56 D05 S35466 Charlton V237206 030805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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. 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