Inspection on 07/12/06 for Charlton

This inspection was carried out on 7th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 10/03/06

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 Grace Agu Key Unannounced Inspection 7th December 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.V320944.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. 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.V320944.R01.S.doc Version 5.2 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.V320944.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 32 persons aged 65 years and over requiring personal care 10th March 2006 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 one person 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.V320944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over eight hours and was undertaken to review the care practices to ensure that it is in line with the legislation and that best practice is being followed at the home. It was also undertaken to review the requirements made at the last inspection to ensure that they have been met. As a part of this inspection, one immediate requirement was made for the home to refer an individual with deteriorating health and weight loss to the General Practitioner and other health professional for appropriate management. A tour of the building was undertaken and a number of records were viewed. Six residents, six staff members and three relatives were spoken with during the inspection. What the service does well: What has improved since the last inspection? It was pleasing to note that the requirement and recommendation made in relation to ensuring that staff receive training on food hygiene and obtaining residents wishes in the event of death also ensuring that more details of outcome of complaint was recorded respectively, at the last inspection had been met. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 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.V320944.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents needs are assessed on admission and they are informed of the homes ability to meet them. However, the home failed to reassess an individual before respite admission. EVIDENCE: The home’s statement of purpose has detailed information about services and facilities to be provided. The home also has a Service Users’ Guide that is given to prospective residents and or their relatives when they visit to enable them to make an informed choice about moving to the home. The care records of two recently admitted residents were viewed. There was detailed assessment from Social Services as well as the home to include physical, mental and social needs Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 9 This assessment was undertaken to ensure that the needs of the resident would be met at the home. One of the residents spoken with confirmed that they visited and were assessed at home before admission. The relatives of two individuals met on the day confirmed that their people were assessed before admission to the home to ensure that their needs would be met, one relative stated, and “my dad and auntie are well looked after here However it was noted that an individual re-admitted to the home for respite was not assessed to ensure that the person’s needs could be met. Terms and conditions of their stay were also noted in the care files viewed. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Doctors and other health professionals are involved care and drug administration practice is satisfactory. However, the home fails to meet the personal care needs of two individuals and the clinical need of another. EVIDENCE: At this inspection three care files were reviewed. Each care file had evidence of pre-admission assessment to enable the home to determine its suitability to meet the residents’ needs. Detailed individualised care plans were noted in most of care the files reviewed followed by daily day and night entries detailing how the assessed needs were being met. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 11 There was also documentation in relation to risk assessments, manual handling and falls. All of the above were regularly reviewed and updated when needs changed. Evidence from the records showed that some of the care plans were signed by the residents or their relatives demonstrating that residents are consulted before developing care plans to ensure that their needs are met holistically. Records showed that an individual was re-admitted from the hospital without appropriate reassessment from the home to ensure that the needs would be met. The duty officer met on the day stated that there was no experienced officer on duty to visit the individual in hospital before discharge and the officers on duty on the day were support workers ‘acting up’ and had no experience on hospital discharges. Observation on the day of inspection, individual’s records and discussion with staff evidenced that the home had not been meeting the person’s personal, nutritional and mental health needs since return from hospital. On the day of inspection it was noted that the individual was slumped in the chair unresponsive and the main meal and pudding were left on the table uncovered and getting cold. The inspector returned 25 minutes later and the person was in the same position unattended. The care file indicated that staff were aware of the service user’s condition. The weight-monitoring chart showed that the individual had lost a significant amount of weight between October and 7 December2006. However, there was no care plan to show how their nutritional, personal and mental health needs were being met. There was no evidence that appropriate health professionals had been consulted to help the home to develop strategies to enable them to meet this person’s needs. There was no evidence noted in the file that the fluid in take and out -put was monitored to prevent the risk of dehydration. These issues were discussed with the manager and an immediate requirement was made for the individual to be referred to the GP and other health appropriate professionals for appropriate management and to consider this person for referral to a different care setting if needs could not be met. There was no response to a request for information relating to how the home met the immediate requirement. It has since come to the notice of the Inspector that the person’s GP was called and the manager has said that the GP confirmed that staff were following the correct plan of care. In addition the Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 12 Commission has been made aware of the resident’s transfer to hospital where there has been a positive response to treatment. Two residents met in the lounge had unpleasant odours due to their medical condition. This compromises their dignity and a requirement was made to ensure that they are adequately monitored to ensure that are clean and comfortable at all times. There was evidence of other health professional visits to include the GP, Chiropodists, Opticians and Dentists. Evidence of wishes in the event of death was noted in the care files reviewed. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. Medicines trolleys are used to transport medication around the home. There is a medicine fridge and temperatures are recorded daily. Controlled drugs were stored correctly and recorded in a register. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home enables the residents to maintain contact with families, friends and local community. It provides meaningful activities and choice in respect of meals and meal times. EVIDENCE: Discussions with residents and staff and entries in the visitors’ book showed that the home actively supports the residents to maintain contact with families and representatives. One resident spoken with stated that their daughter visits every evening. Staff said that the home had no restrictions and families’ visit whenever they like. One relative stated that they visit “every day to see dad. They always give us a cup of tea when we come, the home is home from home”. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 14 One comment card from a relative stated, “Staff are brilliant they always made us feel welcome and there is a very friendly atmosphere at Charlton.” Another comment card stated “I visit my relatives most days and has no hesitation in recommending the home” The home’s activities programme was reviewed. The Manager said that one existing staff member has been appointed to organise activities for residents and this has made a big difference. The staff member is trying different activities aimed to provide better and more stimulation to all the residents and particularly those residents who prefer to stay in their rooms. There is a shop and a bar in house that is open to all residents and visitors. The manager said that the staff member take a mobile shop trolley three times a week to residents to purchase their essentials including toiletries. Residents were making Christmas cards and playing cards with staff on the day of inspection. The manager said in the pre-inspection that the residents are provided with a range of activities to include reminiscence afternoon, bingo, film evening card games, exercise video and one to one sessions. A local church provides Communion for residents once a month. The Duty Manager said that residents were supported to visit the shops for Christmas shopping. Activities for the week were displayed on the board. Activities also book showed names of residents that participated to ensure that no resident feels isolated. The menu on the day contained a choice of two nutritional meals at lunchtime. Residents interviewed stated that they enjoyed the food. However, an individual was not appropriately assisted by staff to have their meal. A requirement is made to ensure that staff are organised to assist this individual at meal times The chef stated that all staff working at the home have attended basic food hygiene training. It was pleasing to note that the home provides meals for an individual from a different ethnic background. The resident confirmed through signing that the meals provided are satisfactory. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 15 The kitchen was not clean. Built up grease was noted in the work top drawers, under the kitchen sinks and the bases of the worktop. The kitchen floor was also noted to be untidy. The chef stated that there was a cleaning schedule, however, the areas identified were not included in the cleaning schedule and that the council is organising a private company to deep clean the kitchen soon. The Chef also said that one of the domestics is taken of the floor from cleaning to assist in the kitchen at lunchtime and goes back on the floor after lunch. This arrangement may put the residents at risk of cross contamination and should be reconsidered for safety of the residents and staff and visitors. The fridge and freezer temperatures were up to date and the foods in the fridge were labelled. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that the home is able to protect them from harm and abuse. EVIDENCE: The home’s complaint procedure contains information to include how to contact the Commission for Social Care Inspection if residents and or their relatives were not satisfied with the outcome of their complaint. This procedure was noted displayed at the entrance hall. Records confirmed that complaints made to the home are recorded and Investigated. In each case the complainant was informed of the outcome of the homes’ investigation. There were no recorded complaints in the complaints book since the last inspection. One relative interviewed stated that she is satisfied with relatives’ care; they are aware of the complaints procedure but they had no complaints. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 17 Two residents spoken with confirmed that they were given complaint procedures and have all the information that they need to make a complaint. The home has a policy on Protection of Vulnerable Adults from Abuse and staff have attended training. There is also a Whistle Blowing Policy and procedure to enable staff to report bad practice without fear of reprisal. Two staff members interviewed stated that they would report any suspected incidents of abuse to the Manager. Two new staff recently employed had Criminal Record Bureau disclosures at the home along with other staff members. It was noted that these were obtained before commencement of employment. Two residents spoken with stated “they felt safe at the home”. Two residents interviewed confirmed that the home supported them to vote at the last election using the postal voting system. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,26,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a generally well-maintained environment, however, it has not provided clean rooms for two identified residents. EVIDENCE: The home is purpose built and provides good all round accommodation. Generally, the home was found tidy, well lit, warm, comfortable and suitable for its stated purpose. The home has a variety of communal areas and activity Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 19 rooms. The communal areas are well furnished and attractively decorated and meet the needs of the current residents. All bedrooms had adequate facilities, personalised and colour coordinated. However, it was noted when touring the building that two resident’s room had unpleasant odour. This was discussed with the manager and a requirement was made for the rooms to be deep cleaned or the flooring replaced to ensure that the resident enjoyed a pleasant and clean environment. The home has a patio and a well maintained garden that the residents are able to use in summer. The laundry was clean with good flooring and ventilation. The washing machines have sluicing programme so that a good infection control is maintained. The Home has Control of Substances Hazardous to Health Policy. The maintenance book was up to date. The work to be done is clearly written in the maintenance book, the manager said that the council organise contractors that come in and do the repairs. Date completed and any relevant comment in relation outstanding jobs is also documented. Residents were noted sitting in the lounge relaxed and enjoying each other’s company. Staff were noted wearing disposable aprons when serving and assisting residents with meals. This demonstrated that infection control and principles of hygiene are being followed. Residents interviewed stated that they felt comfortable at the home. Residents spoken with said that they liked their rooms. One resident said that she/he felt safe at the home. The toilets and bathrooms had grab rails, hoists and other adaptations to meet the needs of current residents. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The staffing level at the home is sufficient to meet the needs of the residents. Staff receive training and are competent, however, identified staff member have not received relevant training to enable them to perform the job effectively. EVIDENCE: Conversations with staff and residents indicated that staffing levels are appropriate to the needs of the residents. Regular visitors to the home expressed the opinion that staffing levels are lower at the home, especially at weekends. Administrative staff do not work at the weekends, but the Duty manager stated that the home provides an extra staff member for three hours on weekends due to high level of needs. There is a robust recruitment policy and procedure in place at the Home to ensure that only appropriate and well-qualified staff are recruited at the Home. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 21 The manager confirmed that all staff have job descriptions in the files and staff spoken with demonstrated knowledge of their roles and responsibility in relation to meeting the residents’ needs. Criminal records of individual staff members were reviewed on the day and were satisfactory. There is evidence of induction programme for all new staff and the Manager stated that a new work book was received from the South Gloucestershire Council that new staff have to complete for twelve weeks to ensure that staff are competent before working independently with residents. However, one staff spoken with stated that it would have been better if the induction programme they received was more detailed. On the day the individual started work, the person was not shown round and was working on their own. Evidence from the staff training records showed that staff have attended training on basic food hygiene, manual handling and Protection of Vulnerable Adults from Abuse, dementia, fire training and medication. However, It was also noted at a discussion that one staff member that was employed in July 2006 had not received any training in relation to protection of Vulnerable Adults, Control of Substances hazardous to Health and Infection Control to enable the individual to perform their duty effectively. A requirement is made to ensure that staff receive appropriate training tailored to protect the residents. One staff spoken with confirmed that they have undertaken National Vocational Qualification (NVQ) at level 2 and some training updates. Residents were very complimentary of staff and the home. One resident states, “staff are very kind, they are very good”. Relatives met at the home states “residents come first here staff are always doing something for the residents”. One comment card received from a relative said “staff are always helpful and very caring, nothing is too much trouble for them.” Another comment card said, “ Mum is very happy at Charlton and is very well looked after. The staff are brilliant, never too busy to discuss or sort things out.” A comment card received from a health professional said “The Charlton House always seem to be a caring home where staff are keen to do their best for the residents. I would be very happy for an elderly relative of mine to be placed here”. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home benefits from good leadership and management approach, some practices have not offered protection to the health and safety of service users. EVIDENCE: The atmosphere at the Home on the day of inspection was positive and welcoming. Staff were noted interacting with residents in an informal and friendly manner. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 23 Staff said that they work as a team and that the Manager has good leadership qualities. These have enabled staff to provide quality care and to support the residents. Residents spoken with made positive comment about the Manager, Mrs Rachael Dawn Brain. One staff member spoken with said, “I have a great respect for her. She knows when to delegate. She is a good manager”. A comment card from a relative states” staff are always approachable and able to help when asked. “Good communication exits between staff and the community team. Many clients have very complex needs but the team appear to manage these clients appropriately”. Staff supervision was reviewed. Evidence from the records viewed showed that staff have received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the exercise. It afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to residents’ care The fire logbook is well maintained. Records showed that fire detection and alarms system were serviced, accidents were accurately recorded. There was evidence of health and safety checks to include water, food, fridge and freezer temperatures. Generic risk assessments of the environment have been carried out. Risk assessments for individual residents are documented in their care files. There were records of fire drill however seven staff members have not attended fire drills. A requirement was made for all staff identified to attend fire drills to ensure that those staff are familiar with the procedure in event of fire. One panel in the hallway was broken with exposed wires and rough edges. It was agreed that the panel identified must be repaired or replaced to prevent potential injury to residents, staff and visitors. A requirement is made for this to be repaired. Quality assurance for the Home was reviewed. The Manager said that the home audits its quality of service using different tools. These include an independent survey commissioned by the Council to obtain feed back from residents, relatives and staff annually. Previous surveys seen were satisfactory. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 24 The home also uses Listening Forms completed by the key workers to obtain comments from the residents about the services provided at the home. Other tools used are feedback from health professionals, one to one discussions with residents following any concerns raised. Medications audit and residents’ money audit. Risk assessment of individual residents and general risk assessment of the home; staff supervision; care plan reviews monthly and when required; health and safety checks; staff meetings and residents meeting. The most recent resident’s meeting was on 30/11/06; issues discussed include new carpet in the lounge and entertainment. The home has policies and procedures to include Protection of Vulnerable Adults from Abuse, Complaint First Aid Missing Persons, Medication, Whistle Blowing, Manual Handling and Infection Control. These have recently been updated. Money held in the safe for residents was checked. The record was up to date and the amount checked was correct. Other residents’ documented information was securely locked away. Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 26 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 OP30 Regulation 18 (1) (c) Requirement Ensure identified staff receive training appropriate to their role including Protection of Vulnerable Adults from Abuse. Ensure a care plan is developed to manage a resident with weight loss Refer identified resident with deteriorating health and weight loss to GP and other health professional as appropriate. Ensure that residents’ dignity is upheld at all times. Deep clean or replace identified flooring to eliminate unpleasant odour in the rooms Ensure that a Gas Safety inspection is undertaken and certificate provided. Provide appropriate assistance to residents who need help with feeding. Ensure that residents are appropriately assessed before being admitted to the home. Repair/ replace the broken box with exposed wires noted in the hallway DS0000035466.V320944.R01.S.doc Timescale for action 01/02/07 2 3 OP7 OP8 15 13 22/12/06 07/12/06 4 5 6 7 8 9 OP10 OP26 OP38 OP12 OP3 12 16 13 14 14 23 22/12/06 30/01/07 30/12/06 30/12/06 30/12/06 30/12/06 OP38 Charlton Version 5.2 Page 27 10 OP38 23 Ensure that seven Identified staff 30/12/06 attend fire drills RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Charlton DS0000035466.V320944.R01.S.doc Version 5.2 Page 29 - 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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