Inspection on 10/05/05 for Charlton Court

This inspection was carried out on 10th May 2005.

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

The inspector 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 Court 19/02/09

Charlton Court 21/08/08

Charlton Court 22/05/07

Charlton Court 19/06/06

Charlton Court 17/01/06

Charlton Court 27/09/05

Charlton Court 07/12/04

Charlton Court 13/05/04

Charlton Court 12/09/02

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

CARE HOMES FOR OLDER PEOPLE Charlton Court 477 479 Bradford Road Pudsey Leeds LS28 8ED Lead Inspector Nadia Jejna Unannounced 10 May 2005 at 10:00 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 Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Charlton Court Address 477-479 Bradford Road Pudsey Leeds LS28 8ED 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) 01274 661242 01274 656799 Charlton Care Homes Ltd Mrs P Moule Care home with nursing 71 Category(ies) of Old age (71) Learning disability (1) Physical registration, with number disability (2) of places Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The place for Learning disability under 65 is for the service user specified in the NCSC Notice dated 2 October 2003. The places for Physical Disability under 65 are for the named service users only. Date of last inspection 15th March 2005 Brief Description of the Service: Charlton Court is a large, purpose built care home, which provides nursing care for up to 71 service users. It is located in a residential area of the Leeds suburbs and is very close to the boundary with Bradford. It provides accommodation on two floors, mainly in single rooms, some with en-suite facilities and has three communal sitting rooms and a dining room. There are wide corridors in the home and a passenger lift; there are facilities for laundering all communal linen and personal clothing and a central kitchen provides all meals (there is, in addition, a kitchenette on the upper floor where drinks and snacks can be prepared). The home has a large car park for staff and visitors. There are grounds to the rear and an outside area where service users can sit comfortably and safely. There are local facilities nearby – shops, pubs etc.- and it is well placed for access to public transport. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced visits. The last announced inspection was carried out over three days from 7th to 13th December 2005. There was an additional unannounced inspection on 15th March 2005 to assess progress made towards meeting the requirements and recommendations arising from the last inspection. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. The purpose of this inspection was to monitor the home’s progress since the last announced inspection and the additional inspection. Also, to assess whether the care given to residents meets minimum standards. During the inspection records were examined, some areas of the home were seen, such as bedrooms, lounges and bathrooms; care staff were observed carrying out their work, and discussions, both on an individual and joint basis, were held with five members of staff, the manager, six visitors, and ten of the residents. Survey cards were left at the home for residents and their relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). This inspection was unannounced and was conducted by two inspectors. The visit started at 10:00 and ended at 17:00 on the 10th May 2005; a second visit of three hours was made to the home to provide feedback to the manager and operations manager on 17th May 2005. What the service does well: What has improved since the last inspection? Some elements of the care plans had improved and it was clear that staff had been working hard to keep these documents up to date. The night care plans were particularly detailed and provided person centred information about the resident. The increased training provision for staff via external facilitators has continued and staff were positive about the benefits of this. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 6 A social activities coordinator had been employed and regular planned activities take place in the home. The activities coordinator was planning residents meetings and actively encouraging residents to be more involved. She was spending time with residents to find out what they like doing and what they would like to do in the future. 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 Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4 and 5. Standard 6 is not applicable to this service. Residents have the choice of home limited as they are unaware of some of the information available. A number of residents are outside the homes registration categories and there is a risk that their needs will not be met as staff are not appropriately trained. EVIDENCE: A resident who had been admitted for emergency respite care had not seen copies of the Service User Guide during the month that they had been at the home. The manager said that copies of this document are kept in every room. The manager said that only that morning she had been told that this persons stay was to become permanent but the resident had not been consulted and did not know about this. Pre admission assessments will be carried out for planned admissions of residents. These would be arranged after the prospective resident and or their relatives had been to look round the home and decide if it would be suitable for their needs. Copies of the homes own pre admission assessment were seen in care plans along with the social services ‘Easycare’ assessments. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 9 The manager is very clear about the homes registration categories and said she would not admit residents out of these categories. However there are a number of residents in the home with dementia who are presenting with challenging behaviour and disrupting day to day living for other residents in the home. The manager said that these residents were already living in the home when she took up her position and she has requested that one of these residents be reassessed and moved to a more appropriate care home. Requirements and recommendations have been made. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10. Residents are at risk of their health, physical, social and psychological care needs not being identified and appropriately dealt with. The dignity and self esteem of residents is not respected by staff. EVIDENCE: Five care plans were looked at. It was evident that staff have been working hard to try and ensure that these records were up to date and that the new care plan formats are being put into use. However the care plans seen were impersonal, task orientated and could relate to any resident in the home. Not all identified needs had appropriate care plans in place and there was insufficient detail around meeting individual’s needs. These included psychological needs of a resident admitted as an emergency, the nutritional assessment of another resident identified them as being at high risk but no care plan around ensuring adequate food intake and monitoring weight was put in place. The night care plans were very detailed, showing a person centred approach and did provide a clear, detailed picture of how to meet the individual’s needs. Care workers are not involved with care planning and their knowledge of residents needs was not as comprehensive as it should be, they said that they can read the care plans but do not get the time to do this. The manager said that there are plans to include the carers with care planning and Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 11 workshops have been held around using the new care plan formats for trained staff. The manager and operations manager facilitated these workshops. It was recommended that they should update their own knowledge and look towards person centred care before planning any further workshops. Pressure area risk assessments are carried out and care plans indicated that appropriate interventions are being carried out. A monthly audit of wounds and pressure sores takes place and their progress is monitored. Records seen stated that that the GP, tissue viability nurse and relatives are informed if pressure sores or wounds develop. The pressure area care policy is being reviewed by the tissue viability nurse before it is put into practice. Pressure relieving equipment is in use but in one instance the setting of an air mattress was too high for the residents weight and build. A system of checking that air mattresses are on the correct settings should be implemented. A large proportion of the residents were seen to have moving and handling needs and assessments are carried out. These should be reviewed as carers were seen assisting residents using handling belts with the aid of two staff when the use of a hoist would have been safer. Staff said that there were issues around the availability of equipment and that they and residents often have to wait for a hoist to become free. This was evident during the day, especially at lunchtime. Some residents were seen with food on their faces after lunch, and others had long, dirty fingernails. Carers said that residents are bathed on request but that they might get a bath once every two weeks. The care plans around meeting hygiene needs did not indicate how often a person wanted a bath and how this would be planned. There was no evidence of resident and or relatives involvement in care planning but visitors did say that staff were good at keeping them informed of any changes. Requirements and recommendations have been made. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Resident’s social care needs meet their expectations and there has been an improvement in social care provision. Residents said that the meals provided were good. However alternatives are not always available for those who do not like what is offered. EVIDENCE: An activities organiser had been employed. There were planned and regular activities morning and afternoon from Monday to Friday. Most of these take place in the larger lounge on the ground floor and all residents are invited to participate. She spends time with residents and tries to see as many as possible during the week. She hopes to find out more about their social and leisure backgrounds and what they would like to do. She is involved with organising residents meetings and encourages the residents to be more involved with these and other activities. A group of residents had been taken to a local garden centre and were looking forward to planting the plants they had bought. At lunchtime she helped to serve meals and assist residents as needed. The revised care plan format contains a document, which provides useful background information about the resident and their likes and dislikes. Information documented should be shared with all relevant staff. In one Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 13 instance where a resident had particularly stated they did not like a food item this had not been passed on to kitchen staff or other carers and they had been given this item on more than one occasion and told that no alternatives were available. This was contrary to what the displayed menu indicated; the chef said that staff asked residents in the morning what the choices were from the menu and that alternatives would be offered. Carers must be made aware that this is an option and make requests to the chef. At lunchtime the tables in the dining room were attractively set and the chef supervised the serving of meals. The food looked tasty and appetising and residents said that the meals were good and they enjoyed them. Many residents were left sitting in wheelchairs to eat their meals and this was not always their choice. This raised concerns about posture and comfort when residents were left in a wheelchair and whether this is conducive towards making mealtimes a pleasurable experience. Visitors said that they can visit at any time and that staff made them feel welcome. Staff and residents said that they choose their own times for getting up and going to bed as well as how and where to spend their day. Some residents prefer to stay in their rooms and others liked to have meals in the dining room and then return to their room. It was clear that staff supported them whatever their choices were. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Residents said that they felt safe in the home, however the records kept of complaints did not show that all complaints made were taken seriously and acted upon. EVIDENCE: A complaints procedure was in place and displayed in the reception area as well as being part of the Statement of Purpose and the Service User Guide. There was a notice in the reception area asking that any concerns or queries be raised with the manager or the person in charge. Forms are available on each floor to record complaints received and these would then passed to the manager to investigate and respond to. However staff said that they often received comments from visitors that they had not heard anything since the initial complaint was made. Two of the care plans reviewed contained details of three complaints made to staff but only one of these was logged in the manager’s complaint file. There were no systems in place for tracking and auditing the progress of complaints made and staff awareness of using the complaints procedure must be improved. The operations manager has been providing staff with abuse awareness training using a video training package. She will be attending a ‘train the trainers course’ with the local adult protection unit in the near future. The homes polices on adult protection did not refer to the local authority adult protection procedures. The reporting procedures should be revised around the reporting process and the highlight the dangers of contaminating evidence. The manager was very clear about contacting the adult protection unit for Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 15 advice before initiating and investigation and this should be reflected in the homes policies. Requirements and recommendations have been made. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 16 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, 22 and 26. Residents are living in a clean, tidy, safe and well maintained home, but they are not able to fully utilise the communal space that is available. EVIDENCE: The home is purpose built and well maintained. There are outdoor areas that can be used by the residents. The activities organiser is working with residents to plan and plant pleasant garden areas. The home has wide corridors allowing easy access for all. There is ample provision of communal space but it is mostly on the ground floor. Now that there are more residents living in the home the use of communal areas should be reviewed. There is only one small lounge upstairs, which also serves as a dining room for those residents who use it. The dining room downstairs is not big enough to accommodate all the residents in one sitting. The smoking room is a very large lounge area that is under used because there are very few smokers living in the home. Discussions were held with the manager and operations manager about reviewing these rooms usage and allocating an alternative room as the designated smoking area. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 17 The communal areas are furnished with a variety of chairs. It was concerning that some residents were sat in chairs inappropriate to their height and build. A number of ‘bucket’ style chairs were in use. These chairs could be used as a form of restraint. The manager said that it was by residents choice and for their comfort. If these types of chairs are to be used appropriate risk assessments must be in place and agreements obtained from the resident and or their representatives. There was a fault with the call bell system, an indicator light did not turn off, which had not been reported. This could cause confusion for staff and lead to calls for help not being responded to. The manager did deal with this promptly when she had been made aware of it. The home was clean and tidy and there were no odours. The housekeeper said that all laundry is now done in house. The manager was advised to review the provision of laundry equipment in order to ensure that it would meet the needs of a full home. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 18 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, 29, and 30. Staffing levels are inadequate to meet the needs of the residents. EVIDENCE: Staff, residents and visitors said that there were never enough staff on duty. It was evident that the staffing levels were not appropriate for the numbers and high levels of needs of residents in the home. Call bells were not being answered promptly and residents had to wait a long time for staff to come and attend to their needs. A resident said that they had opted to eat finger foods rather than meals because staff did not have the time to come and help them to eat normal meals. The manager had forwarded details to the CSCI of proposed staffing levels to be used as a guideline as resident numbers increased. It was evident from staff rotas that these had not been followed. The staff rotas showed that some of the staff are regularly working more than fifty hours per week. Staff sign a waiver to the ‘working times regulations’ but as there is no formal systems of supervision in place their health and well being is not monitored. This issue must be reviewed urgently as there is a health and safety risk to residents and staff. Training provision in the home has continued to improve. Staff were positive about training received and planned. There were notices advertising future training sessions. Examples included health and safety, food hygiene, diabetes and stoma care. The manager and the operations manager are attending ‘train Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 19 the trainer’ courses. When these are successfully completed they will be providing training around fire safety and adult protection as well as moving and handling. A ‘care planning’ workshop was held for the trained staff to introduce the new care plan formats. Records seen showed that only three attended. The manager and the operations manager facilitated this. They have not updated their knowledge around care planning; it was recommended that they should do this before providing further training and that they should look at person centred care models. Comments made on survey cards returned said that there were language barriers between the residents and some of staff who do not have English as their first language. Files for two recently employed staff were seen. These showed that most required checks and information were in place. There were no written explanations for gaps in employment and the CRB disclosure information did not confirm that satisfactory POVA checks were in place. Requirements and recommendations have been made. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 20 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) 32, 36, 37 and 38. The manager is approachable, however action is not always taken to resolve issues. Communication systems do not ensure that everyone receives the necessary information. EVIDENCE: Staff said that they could not remember when the last meeting was held. They felt that staff were supportive of each other and they could approach senior staff and management for advice and support. However staff did say that the culture and organisation of the home could be improved; comments made were around low staffing levels, raised stress levels and the feeling that they were unable to make progress implementing changes. A poster was on display advertising a residents meeting that was due to be held in the near future. Visitors said that staff kept them informed of any changes. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 21 Staff said that they had not received formal supervision. Resident’s records are kept in lockable cabinets but there were open and accessible to anybody. Not all of the records that must be in place were available. These included photographs of residents and complaints records. Accident records were available and provided sufficient information. Lap belts were being routinely used for a number of residents who sit in wheel chairs to eat their meals. Risk assessments were not in place. Requirements and recommendations have been made. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 22 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 2 x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 x 2 x x x 2 STAFFING Standard No Score 27 1 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x 2 x x x 1 2 3 Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 23 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. Standard 1 Regulation 4,5,6 Requirement The Service User Guide must be revised to ensure that required information is available to current and prospective service users.(Previous timescales which have not been met are 31.3.04, 30.11.04, 31.3.05. This requirement was not assessed on this ocassion and the timescale has been extended.) The manager must ensure that the home can meet the assessed needs of all service users admitted to the home. Relevant training must be provided for staff to ensure this. Where it has been identified that the home is not meeting identified service user needs, the manager must ensure that these placements are reviewed. (Previous timescales which have not been met are 31.3.04, 30.11.04, 31.3.05.) A plan of care must be in place for each service user, which details clearly how all assessed health, personal and social care needs will be met. These must evidence all actions taken and provide an accurate picture of Timescale for action 30.9.05 2. 4 14 30.9.05 3. 7 14,15 30.9.05 Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 24 4. 8 12,13 5. 8 13 6. 9 13 7. 10 12 the service users medical, physical and social well-being. Staff must be trained in writing care plans and appropriate systems put in place to ensure this. The care plans must be kept under review and reflect changing care needs. The service user and their representatives must to be involved in this process. (Previous timescales which have not been met are 31.10.03, 31.3.04, 30.11.04 and 31.3.05) The pressure sore prevention policy must be implemented with all staff when it has been reveiwed by the tissue viability nurse. Appropriate training must be provided to staff. Appropriate measures must be taken to ensure that pressure relieving equipment is maintained in good working order and that correct settings are used. (Previous timescales which have not been met are 31.10.03, 31.3.04, 30.11.04 and 31.3.05.) The registered person must ensure that there is adequate provision of moving and handling equipment for the needs and numbers of service users. The homes drugs policies and procedures must be revised in line with the Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes and must be implemented with all staff. (This standard was not assessed on this inspection and it was agreed to extend the previous timescale of 31.1.05. Previous timescales which have not been met are 31.10.03, 31.3.04, 30.11.04 and 31.1.05.) The registered person must 30.9.05 30.9.05 30.9.05 30.9.05 Page 25 Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 8. 12 16 9. 16 22 10. 18 13 11. 20 16,23 12. 22 23 ensure that the home is conducted in a manner that respects and maintains the dignity of service users. Previous timescales which have not been met are 31.3.04, 30.11.04 and 31.3.05.) Provision must be made to ensure that service users social, leisure and recreational needs are identified and met. Records should be kept. (Previous timescales which have not been met are 31.3.04, 30.11.04 and 31.3.05.) The registered person must ensure that all complaints received are documented, fully investigated and that writen responses are provided to the complainant. A system of auditing and tracking complaints should be implemented. The registered person must ensure that all staff are provided with adult protection training by persons who are qualified and competent to do so. The registered person must review the provision of seating in communal areas to ensure that chairs are provided suitable to the needs, size and build of service users. Where chairs could be used as a form of restraint, appropriate risk assessments must be put in place and consent for their use obtained from the resident and or their relatives. The call bell system must be repaired and maintained in good working order. The registered person must ensure that there are sufficient numbers of accessible bathrooms 30.9.05 31.8.05 30.9.05 30.9.05 13. 21 23 Immediate as discussed with the manager. ongoing Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 26 14. 27 18 for the numbers of service users in the home. A copy of proposed plans and timescales must be forwarded to the Commission.(Previous timescales, which have not been met are 30.11.04.) The registered person must ensure that there are adequate numbers of staff on duty to meet the needs of residents. 15. 27 18 16. 29 19 17. 30 18 18. 27 and 30 18, 19 19. 32 and 33 21 Systems must be in place to monitor the number of hours worked per week by staff in order to ensure their continued safety and well being. The registered person must ensure that the recruitment documentation includes evidence that the candidate is not on the POVA register and written confirmation that gaps in employment have been explored. ongoing The registered person must ensure that the training programme is implemented with all staff and which meets TOPSS and NTO training targets. This must also include care planning and person centred care, training in record keeping for all staff, but particularly trained staff; wound care; accountability and responsibility for trained nurses as per the requirements of the NMC Codes of Professional Conduct. The registred person must ongoing ensure that all staff can communicate effectively with service users. The registered person must 30.9.05 make arrangments to enable staff to inform them of their views as to the conduct and organisation of the care home Version 1.30 Immediate as discussed with the manager. Immediate as discussed with the manager. Immediate as discussed with the manager. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Page 27 20. 33 21. 33 22. 36 23. 37 24. 38 25. 38 and how it affects the health and welfare of service users. 10,12,24 Identified requirements on inspection reports must be met within the agreed timescales.The results of the service user survey must be made available to all interested parties. (This standard was not assessed on this inspection and the previous timescale of 31.3.05 has been extended to 30.9.05.) 26 The registered provider must ensure that monthly visits to the home take place and that reports are kept, copies of which must be sent to the CSCI.(This standard was not assessed on this inspection. The previous timescale of 31.1.05 has been extended to 30.7.05.) 18 The programme of supervision must be extended to ensure that staff receive formal supervision at least six times per year. Records must be kept. (The previous timescale of 31.3.05 was not met.) 17 All records as outlined in schedules 3 and 4 of the Regulations must be available in the home. Records must be kept securely as per the requirements of the Data protection Act. (Previous timescales, which have not been met are 31.3.04 and 31.12.04). 13, 18, 23 Mandatory training in safe working practices must be provided for all staff and updates provided as required. Records must be kept. 13 The registered person must ensure that no service users are subject to physical restraint. If the types of restraint used are the only practibable means of ensuring service users safety J52 S1330 Charlton Court V226043 100505 Stage 4.doc 30.9.05 30.7.05 30.7.05 30.7.05 ongoing Immediate as discussed with the manager. Page 28 Charlton Court Version 1.30 and welfare appopropriate risk assessments must be put in place and consents obtained from the service user and or their representatives. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations The registered person should review the admission procedures in order to ensure that service users and relatives are aware of where to access information about the home. The registered person should ensure that all service users and or their representatives are given copies of the homes contracts/terms and conditions of residence. Copies of which should be available for inspection. (This standard was not assessed on this inspection and the recommendation has been carried forward.) The registered person should ensure that systems are in place to inform staff of service users dietary likes and dislikes and that appropriate choices are offered and avialable to them at mealtimes. The registered manager should review seating arrangements at mealtimes. The adult protection polices and procedures should be revised to include contact details for the local adult protection unit, updated reporting procedures and advice on the dangers of contaminating evidence. The registered person should review usage of communal areas and consider reallocating the designated smoking area in order to provide more communal space to all residents. The manager should review the provision of laundry equipment in order to ensure that it would meet the needs of the full home. The infection control policy must be revised following consultation with the infection control nurse and other sources of relevant information. This policy must be implemented with all staff. (This standard was not assessed on this inspection and the recommendation has been carried forward.) J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 29 2. 2 3. 15 4. 5. 15 18 6. 20 7. 8. 26 26 Charlton Court 9. 27 10. 28 11. 12. 30 32 The registered person should review the trained nurse staffing hours to ensure that they have sufficient time to fulfil their duties and responsibilities particularly with regard to care planning and documentation. The registered person should ensure that at least 50 of staff achieve NVQ level 2 by 31st December 2005. (This standard was not assessed on this inspection and the recommendation has been carried forward.) Training facilitators should be qualified and competent to provide training to staff and be able to provide evidence that their knowledge is current and up to date. The registered person should review the organisational and management systems within the home. Charlton Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 Court J52 S1330 Charlton Court V226043 100505 Stage 4.doc Version 1.30 Page 31 - 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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