Inspection on 22/05/07 for Charlton Court

This inspection was carried out on 22nd May 2007.

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 Court 19/02/09

Charlton Court 21/08/08

Charlton Court 19/06/06

Charlton Court 17/01/06

Charlton Court 27/09/05

Charlton Court 10/05/05

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 West Yorkshire LS28 8ED Lead Inspector Paul Newman Unannounced Inspection 14th June 2007 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 Court DS0000001330.V337302.R02.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 Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlton Court Address 477-479 Bradford Road Pudsey Leeds West Yorkshire LS28 8ED 01274 661242 01274 656799 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) Charlton Care Homes Limited Mrs Pamela Moule Care Home 71 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (71), Physical of places disability (2) Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 One specific service user under the age of 65, named on variation dated 20th December 2006, may reside at the home. Date of last inspection Brief Description of the Service: Charlton Court is a large, purpose built care home, which provides care, with nursing, 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 that provides all meals (there is, in addition, a kitchenette on the upper floor where drinks and snacks can be prepared). There is a large car park for staff and visitors. There are grounds to the rear and an outside area where residents can sit comfortably and safely. There are local facilities nearby - shops, pubs etc.- and it is well placed for access to public transport. Information about services provided by the home is available in the home’s combined Statement of Purpose and Service User Guide. Copies are kept in the reception area and can be taken by relatives or visitors. The weekly fees are from £420 to £550 per week. These charges do not include hairdressing or chiropody and a separate list of charges for these and other services is available from the provider. This information was supplied in the pre inspection questionnaire in April 2007. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group, for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last inspection was carried out in June 2006. This report is of a key inspection, made on an unannounced basis. One inspector made two visits to the home on consecutive days and spent a total of 13 hours on site. Key inspection reports are available on the CSCI website. The inspection process is ongoing and the home has been monitored since the last inspection through information that is required to be sent to the CSCI about significant events, complaints and regular monthly reports about the conduct of the home carried out by the provider. About two months before the inspection visit, the Provider was sent a Pre inspection questionnaire to complete and this was returned promptly. This contains a lot of information that helped in planning the site visit. Survey questionnaires were also sent out and there was a good return from relatives, people using the service and visiting healthcare professionals. This also helped in planning areas to focus attention on the site visit. During the site visit records were checked, a tour of the premises was made and most of the staff on duty were spoken with. Several residents were spoken with including some who had lived at the home for a lengthy period and some who had recently arrived. Several people who were visiting residents were spoken with and a Community Matron working on a project that involves the home was spoken with. On the second day a focused observation was made of staff at their work on the ground floor and first floor. This was done over a four-hour period beginning at the start of the early shift at 7.30am. This was specifically done to gain a better understanding of what it is like to live in the home and assess whether people using the service are receiving good quality care. Verbal feedback was given to the Operations Manager and the Registered Manager at the end of the second day. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 6 What the service does well: The manager appears ‘on top of things’ and has gained the confidence of the staff team, raised morale and made sure that training has been provided. The staff are committed and enthusiastic about their work and like to deliver a high quality service. They are excellent in the way they deal with people living at the home. Relatives and people using the service are generally satisfied and some written comments that have been made are: • • • ‘Treats my father as an individual giving him a very caring environment in which to live’ ‘RGN rings to let us know every time our relative goes to hospital and the outcome’. ‘Staff always keep a good check on residents health and keep us updated. Always pleasant and caring to residents. Always ready to discuss anything with us if we have concerns’. ‘Charlton Court is a very friendly place to visit. All staff are respectful of each other and individuals living in the home’. ‘When observing carers doing tasks with individuals they always respect privacy and dignity’. ‘The care staff are magic and work very hard. friendly and polite to both visitors and residents’. They are pleasant, • • • • ‘Staff are very helpful when there are visitors – nothing is too much trouble for them’. What has improved since the last inspection? The level of complaints has significantly fallen and the feedback from residents and relatives is much improved. In the last inspection report there were eleven requirements and with the exception of one, all have been resolved. This is very positive. As a consequence the record keeping in relation to care plans and risk assessments has improved. The conversion of a bathroom to a walk in shower is almost completed. People living at the home are not complaining that the emergency call system is not answered promptly and observations made during the inspection verified that practices are much improved. The manager has successfully completed the registration process with the CSCI and further Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 7 progress has been made in achieving targets for fifty percent of the care staff having National Vocational Qualifications. A staff supervision system has been established. The level of complaints has significantly fallen and the feedback from people living at the home and relatives is much improved. 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 Court DS0000001330.V337302.R02.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People who may use the service and their representatives have the information they need to choose a home that will meet their needs. Peoples’ needs are properly assessed before admission. EVIDENCE: The current statement of purpose and service user guide is being reviewed. Currently these are two documents but the organisation is considering revising this to one more easy read and ‘user friendly document. The registration certificate was reviewed and discussed during the site visit in line with changes the CSCI wants to make. Account will be taken of this in the evaluation of the Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 10 statement of purpose. Information currently provided meets the standard. And provides people with accurate information about the services provided. From the discussions and case tracking that was carried out that included checking four case files it showed that the registered manager carries out most pre-admission assessments of people before they are admitted to the home. The pre-admission process is thorough and includes a summary of the main issues, family circumstances and any specialist equipment that might be required. Where possible the person who intends to use the service visits the home but where this is not the case, their family or representative always visits to gain information. One relative said that they had been given a list of as number of homes to choose from by a social worker. She visited each of the homes without a prior appointment feeling that this was the best way to see each home. She was most impressed by the way she was received and welcomed at Charlton Court, that the staff spent plenty of time showing her round and explaining things and that she was given the service user guide. She said this was far more positive than the approach taken by other homes and on the basis of what she saw and was told decided that her Mother would be best cared for at the home. She remains pleased with the care provided. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The care plans provide clear and detailed instructions for staff to follow making sure that health and personal needs are met. The people at the home are treated with respect and dignity. EVIDENCE: A selection of four individual case records was looked in detail and the care of those people case tracked. The individual records included an overview of the main areas of support needed that were identified from the pre-admission assessment. Specific care plans provided the detail of how the person’s care needs can be met and identify strengths and weaknesses where this is possible. Each of the care Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 12 plans had been reviewed and evaluated on a monthly basis and there were examples of this being sooner if a new need was identified and care needs had changed. The surveys that were returned and the conversations with relatives showed that people feel that staff keep them up to date with changing care needs and the files showed signatures to show that the care plan had been explained and agreed. The language was straightforward and easy to understand. Personal histories are now completed and this helps staff in their understanding of individuals and in developing their relationships and conversations with residents. The histories also include profiles of the person’s likes and dislikes across a range of person centred areas. A full range of risk assessments was carried out and included risk assessments for mobility, falls, manual handling, nutrition, continence, night checks and in one person’s case a risk assessment for going out independently. These were up to date with plans in place of how to manage any identified risk date to make sure that they reflect the care being given. Daily records were recorded in greater detail than at the previous inspection and related to the specific plans for care. Changes in condition were documented and monitored and where there was a need to seek medical advice this could be tracked on the record of professional visits. End of life plans are being introduced and the manager is interested in joining the gold standards framework award that will develop services for people nearing the end of their life. This will also increase training opportunities for the home. Three relatives of people living at the home said that they were more than satisfied with the care provided. They all commented on the caring qualities of the staff and the way that staff kept them informed. Some of the written comments made in surveys that were returned included: • • • • ‘Treats my father as an individual giving him a very caring environment in which to live’ ‘RGN rings to let us know every time our relative goes to hospital and the outcome’. ‘The staff hoist and transfer with care and attention’. ‘Staff always keep a good check on residents health and keep us updated. Always pleasant and caring to residents. Always ready to discuss anything with us if we have concerns’. A survey from a community nurse stated that the staff are: • ‘Enthusiastic and motivated to improve the care to residents. Work well with limited staffing numbers for highly complex needs client group’. DS0000001330.V337302.R02.S.doc Version 5.2 Page 13 Charlton Court The home is involved in a project with the local Primary Care Trust and a Community Matron is based at the home for three days a week. She had no concerns about the competency of nurses and carers and felt that her involvement in the home was increasing their confidence. The home is encouraged to use her experience and knowledge to further develop expertise in particular about identifying healthcare issues early. Medication practices were observed over the two days and checks made of drugs administration charts and drug storage. Nurses were taking the necessary care in administering the correct drug to people and it was good to see that the nurse used this as an opportunity to have a conversation and check out any problems and to give reassurance. Staff were knowledgeable about service users, could put names to faces and knew which rooms people occupied. They were observed and overheard to be cheerful and friendly and to spend time communicating with people with sensory loss and actively listening to peoples’ fears. It was clear from overheard conversations that people were given choices and able to make decisions about their daily lives. Some written comments made in surveys that were returned were: ‘Charlton Court is a very friendly place to visit. All staff are respectful of each other and individuals living in the home’. ‘When observing carers doing tasks with individuals they always respect privacy and dignity’. Whilst the focused observation on the second day showed some shortfalls in staffing levels, the observations clearly showed the commitment of the staff to treat people with respect and make sure that they were dignified in the way they dressed and looked. Attention was given to make sure that people were properly assisted and where personal care tasks were involved staff made sure that doors were closed and that people had they privacy they needed. This was a really positive feature noted over the two day visit. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 14 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): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Opportunities for people using the service to engage in activities are to be improved. Service users are able to choose their lifestyle and keep in touch with relatives and friends inside the home. The home offers a healthy, varied diet. EVIDENCE: Some of the surveys that were returned from relatives and people using the service suggested that the previous good range of activities that had been provided had decreased. Some comments made were: ‘Not enough activities – perhaps if more staff were employed they would have time to arrange activities on a regular basis. Very little stimulation’ Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 15 ‘There are summer trips out and parties for Xmas Easter and Halloween, but bingo, quizzes, exercises and any other daily activities seem to have come to a stop several months ago’. Over the two days of inspection at the home there was little in the way of activity apart from TV and staff were extremely busy making sure that peoples’ basic care needs were met. The home previously employed an activity organiser and the last inspection report noted her commitment and enthusiasm. She has left the home and the post had been vacant for about three weeks at the time of the inspection. This fully explains the comments made in the surveys and by the people spoken with, although some said that they would not join in activities because they much prefer to spend time in their rooms, doing their own thing. A new appointment has been made and the manager is pleased that the new person offers the same commitment but is also able to work quite flexibly which will increase opportunities for activities in the evenings and at weekends. The activity organiser will be taking appointment as soon as the necessary checks have been made. The home encourages families and friends to visit and this is made clear in the service user guide. The survey results showed that relatives feel welcome at the home. Some typical comments made were: ‘The care staff are magic and work very hard. They are pleasant, friendly and polite to both visitors and residents’. ‘Staff are very helpful when there are visitors – nothing is too much trouble for them’. The relatives spoken with during the visit also said that they felt welcomed and staff were friendly and helpful. The survey results and conversations with people living at the home or their relatives, in general suggest that people are able to make choices about their lifestyles. Superficially this appeared to be the case. People apparently got up when they wanted and sat where they wanted, either in their rooms or lounges if they preferred. They certainly exercised choice in the way they dressed and the staff were seen to encourage individuals to think about the way they looked and their appearance. However the focused observations on the second day were able to throw a more qualitative assessment on this. Comments are made about staffing levels in the later section about staffing that covers Standard 27. The conclusion of the focused observation was that reduced numbers of staff on duty (because of reduced occupancy) was affecting the quality of service experienced by individuals. This was most obvious at times like the early morning when staff needed to assist residents with personal care and getting up out of bed. In discussions with them, people using the service Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 16 appear to accept that staffing levels will dictate the time they get up in the morning and this to some extent dictates the speed with which they have their breakfast. But the base line was that there was little choice and people fitted in because ‘that was the way it was’. There is no suggestion that staff are not organised, did not know who likes to go to the dining room to eat, or eat in the lounge or eat in their rooms. But the whole process of getting people up, attending to their personal and nursing care needs and medication started at 7.40am and did not finish until 11.10am. Whilst staff were skilled and personable in the way they managed people there was no real room for flexibility. Those individuals who were up earlier and had an earlier breakfast and sat in the lounge spent most of the time without staff in the room. The TV was on but there was little interest in it. People were just sitting with their own thoughts and in a passive state. By the time staff had finished the early morning routine it was almost time to start getting people down to the dining room for lunch. Here too, staff were skilled in the way they did this but there were just not enough staff and some individuals who were in the dining room early were not getting the assistance they needed with feeding. The meal time did not feel like a social occasion – more like a cafeteria with people coming in and out, getting the task done and then leaving with little interchange between people at the home and the staff. The menus were seen and these look to provide choice and good nutritional value. Pureed food was presented well so that people could benefit from the different tastes in the meal rather than it all being blended together. The chef continues to try hard to be personable and get around the people living in the home to check that they are happy with things. Any grumbles that were mentioned during the inspection were about the quality of the food when the chef is not on duty. There is currently a vacancy for weekends and this is being covered by agency cooks whose performance is variable. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 17 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 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. There is a clear complaints procedure available to the people at the home. The people who live at the home feel confident that they will be listened to and that appropriate action will be taken when necessary. There are robust adult protection procedures and staff have received training. People can be assured that they can feel safe at the home. EVIDENCE: There is an effective complaints procedure in place, which is displayed in the entrance area to the home. A file of complaints is kept and included the records of complaints received at the home since the last inspection. The records demonstrated that complaints are taken seriously and dealt with appropriately. The manager provides training in adult protection and is familiar with the local authority procedures. The training is ongoing and staff receive annual update. In addition adult protection is included in National Vocational Qualification (NVQ) training. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 18 Comments made in the surveys and in conversations with people living at the home and relatives suggest that people are aware of the complaints procedure and feel confident in raising concerns with staff and that they will be listened to. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 19 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 and 26. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People live in a safe and well maintained environment. EVIDENCE: The home was clean and tidy and there were no odours. The laundry was tidy and well organised and residents clothing looked well laundered. The manager said that there is an ongoing programme of redecoration and written programme was provided. There are systems of checking rooms and the building and the regular audits were seen. These had however, failed to note that some of the guttering was blocked and this was reported to the Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 20 manager. At the time of the inspection some bedrooms were being redecorated. The home has been successful in being awarded a Local Authority improvement grant and this is going to be used to improve access to the grassy areas of the gardens and build additional flowerbeds. The provision of a summerhouse or gazebo is under discussion as part of this project. The home employs a maintenance person and the manager described the newly appointed post holder as excellent and enthusiastic. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The numbers and skill mix of staff were insufficient to meet the needs of the people living at the home. Staff receive the training they need to do their job. Robust recruitment procedures protect the people living at the home. EVIDENCE: Some of the surveys that were returned suggested that there were not enough staff on duty. On the first day of the inspection a number of the staff were spoken to and consistently said that they felt ‘under pressure’ and unable to give the people the time and attention they needed although they did feel that basic needs were met. The Community Matron working at the home as part of a project with the PCT also was very clear in her statements that she felt there were insufficient staff. As a consequence of this it was decided to make an unannounced early morning visit the following day to specifically observe staff at their work. Staff had said that they were working with one qualified nurse and two carers on the Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 22 ground floor and one qualified nurse and four carers since the beginning of April this year although management had told them that eight carers in total would be the norm and there was a notice in the staff room to support this. Staff said that at times it could be just three carers on the first floor. Dependency levels are high and most people need two staff to support them in personal care and/or moving and handling. The pre inspection information provided by the home showed that thirty-six people were doubly incontinent. Staff said that some people who needed assistance with eating could take a long time even up to forty-five minutes. Both floors were observed over a four-hour period. Staff were skilled in their dealings and management of the people living in the home but the conclusions of this focused observation were as follows: • • • There were insufficient staff on duty. Staff could not afford people the time and consideration that was fully needed to make individuals feel valued. Staff were dealing with personal care immediately followed by handing food and assisting people with their meal. Whilst they observed good hygiene practices the fact that they were doing this increased the possibility of cross infection. The volume of people with medication requirements means that the time to do the medication administration is extended. Throughout this phone calls or visitors, can distract the nurse dealing with medication, therefore increasing the possibility of errors being made. People who like to spend their time in the lounge were observed to be in a passive state with little interaction from staff who were busy elsewhere. Even when the nurse was able to spend time in the lounge, the need to complete records that are required meant that this was done at the same time. There were not enough staff to support and assist people in the dining room. The lack of numbers of staff limits some aspects of choice that an individual should be able to make. • • • • In the verbal feedback there was little the manager and operations could say to the detailed observations that were made and an immediate commitment was made to make sure that a total of eight carers would be on duty throughout the waking day starting the next day. The numbers of qualified staff were also discussed and a commitment to provide three nurses when occupancy reaches fifty was made. The registered manager is also a qualified nurse and the level of support that she can directly provide in the interim period is to be reviewed. Whilst the conclusions above mention the possibility of things going wrong, there was no evidence to suggest this was the case. Drugs administration records showed no errors. Nursing staff and care staff practices were sound. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 23 Accident levels were checked and in particular the lounge areas that were least supervised during the inspection. In fact accident levels overall have surprisingly decreased. The files of three newly recruited staff were checked to make sure that staff are properly recruited and the necessary references and checks are made. These were well organised and had all the necessary documentation. Discussions with individual staff and review of the training records show that the planned programmes of training are being sustained and a copy of future training sessions was provided. With the numbers of staff currently undertaking National Vocational Qualifications and those who have already completed, the home is in a healthy position and will achieve the fifty percent target of the total number of care staff. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 24 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, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The home is well managed. The interests of the people who live there are seen as very important to the manager and her staff. Regular auditing and checking of facilities, equipment and services make sure the home is a safe place to live. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 25 EVIDENCE: The manager is an experienced nurse and since the last inspection has completed the registration process with the CSCI. Twelve months ago under a different manager the home was struggling under poor management practices so the new post holder has done well to turn things around. Whilst there is always room for improvement the manager appears ‘on top of things’ and has gained the confidence of the staff team, raised morale, made sure that training has been provided. The level of complaints has significantly fallen and the feedback from residents and relatives is much improved. There is what is now an established quality management system that includes a schedule of auditing and checking. Satisfaction survey questionnaires have been sent out by the home in April this year and the results have been collated into a summary report that all visitors can see. Actions that the home felt they needed to take as a result are identified in the report. In addition the Company is now fulfilling its legal responsibility to make monthly reports on the conduct of the home each month. These are completed by the operations manager and have provided good information that indicated the home was making every effort to resolve issues that were raised in the last inspection report. Some money is held for safe keeping for some people. Individual records are kept of these that show all income and expenditure with receipts to support this. Each transaction is signed for either by two staff members or the individual/relative and staff. The pre-inspection information demonstrated that safety checks are made of the facilities, equipment and services on a regular basis and during the inspection fire safety records and accident records were checked. Staff are up to date with safe working practice training and have been involved in fire drills. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 27 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 OP12 Regulation 16 Requirement Timescale for action 31/07/07 2. OP14 16 3. OP27 18 The registered person must make sure that people are consulted and provided with a range of activities to interest and stimulate them. The registered person must 31/07/07 make sure that the home is run in a way that increases opportunities for people to make choices and take control of their own lives. The registered person must 31/07/07 ensure that there are enough staff on duty to meet the needs of people. The size and layout of the building must be taken into consideration along with the physical, psychological and social needs of the people. Outstanding from 31/05/06 Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 28 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 OP8 OP37 Good Practice Recommendations The registered persons are encouraged to work closely with the Community Matron currently working in the home to develop nursing staff confidence and skills. The registered person should introduce a policy on sexuality and relationships so that staff have some clear guidance to assist them when issues arise. Charlton Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Court DS0000001330.V337302.R02.S.doc Version 5.2 Page 30 - 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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