Inspection on 11/06/07 for Charlton Park Care Centre

This inspection was carried out on 11th June 2007.

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 Park Care Centre 14/12/09

Charlton Park Care Centre 15/12/08

Charlton Park Care Centre 16/06/08

Charlton Park Care Centre 19/12/07

Charlton Park Care Centre 27/02/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Charlton Park Care Centre Park Farm, Off Cemetery Lane Charlton London SE7 8DZ Lead Inspector Maria Kinson Unannounced Inspection 11th June 2007 09:35 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 Park Care Centre DS0000068284.V338150.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 Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlton Park Care Centre Address Park Farm, Off Cemetery Lane Charlton London SE7 8DZ 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) 020 8316 4400 020 8316 4422 charlton.park@fshc.co.uk Four Seasons (No 7) Limited Care Home 66 Category(ies) of Dementia (34), Mental disorder, excluding registration, with number learning disability or dementia (1), Old age, not of places falling within any other category (31) Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mental Health nursing care 35 patients aged 55 General nursing care 31 patients aged 55 Date of last inspection 27th February 2007 Brief Description of the Service: This home is located in Charlton, within walking distance of local bus routes and Charlton village. The home consists of a 31-bedded unit for older people that require nursing care on the ground floor and a 35-bedded unit for older people with dementia that require nursing care on the first floor. All of the bedrooms are single occupancy with a private toilet and hand washbasin. Laundry and kitchen facilities are provided on site. There is a garden at the rear of the property and 17 parking bays in the area in front of the home. The fees charged by the home range from £579.24 - £629.24 per week. This does not include additional charges such as chiropody and hairdressing. This information was supplied to the commission on 07.06.07. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 11th June 2007 and was unannounced. Two inspectors spent nine hours in the home observing care practices, examining records, assessing the environment and speaking with some of the residents and staff and three visitors. Comment cards were sent to ten residents, twenty-six relatives and seven health care professionals. The commission received two comment cards back from health care professionals, eight from relatives and one from a resident. The information provided by residents, relatives and other professionals forms part of this report. There were twelve empty beds at the time of this inspection. A CSCI pharmacy inspector carried out an unannounced inspection on 23/05/07. The findings from this inspection are included in this report. What the service does well: Staff obtained information about peoples needs before they moved into the home. This information was made available to staff. People that could make decisions for themselves were able to choose how and where they spent their time in the home and were encouraged to be as independent as possible. Relatives were satisfied with the visiting arrangements and said that they were able to visit their family member when they wanted and in private. The choice of food provided was good and residents were supported to eat if necessary. Most people said they enjoyed their meals. Complaints were investigated and responded to in a timely manner. Most relatives were familiar with the homes complaints procedure and said staff responded appropriately when they raised concerns. Staff had access to regular training sessions and were supported to attain recognised qualifications. The building was maintained to a satisfactory standard and most areas were clean and tidy. Personal money and valuables were stored securely and records were maintained to show how the money was used. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The management of medication was poor. The pharmacy inspector found that several residents were not receiving their prescribed medication and some records were not properly maintained. Regular activities were taking place but some resident’s did not receive adequate support to take part in activities. People did not have an opportunity to go out or to engage with the local community. The activities coordinator had not received any formal activity training. Some checks were undertaken to assess the suitability of new staff but references were not always verified to ensure that they were genuine and there was no evidence that the home had confirmed if one of the nurses that was working in the home was able to practise. The duty rosters were difficult to interpret and provided conflicting information in parts, about staff that had worked in the home. There were occasions when the home did not have adequate staff to meet people’s needs. Most relatives were satisfied with the care provided for their family members but two relatives said that there was a “lack of communication between staff and residents” and one resident said that staff did not have time to talk. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 7 There were systems in place to obtain feedback about the service and to monitor the quality of care provided in the home but this information was not always shared with the people using the service. Health and safety records were good overall but the gas safety record could not be located and some records did not provide adequate information. 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 Park Care Centre DS0000068284.V338150.R01.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 Park Care Centre DS0000068284.V338150.R01.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): 3 (standard 6 does not apply to this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information obtained during the assessment helped staff to decide if the service would be able to meet people’s needs. EVIDENCE: Prior to admission the manager or a senior member of staff assessed prospective residents needs. The assessment identified the person’s physical, mental and social care needs and provided other useful information such as a list of their current medication. Staff used the assessment record and written information that was provided by the funding authority to decide if the service would be able to meet the person’s needs. Charlton Park Care Centre DS0000068284.V338150.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 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff had started to develop care plans that were based on people’s individual needs and preferences. Some medication records were not properly maintained and some residents had not received all of their prescribed medication. This could affect people’s health and wellbeing. EVIDENCE: Two care plans were examined on each unit. The quality of information recorded had improved and care plans provided more information for staff about how they could meet people’s individual needs. It is essential that staff sustain the improvements that were seen during this inspection as many of the people living in the home are not able to tell staff what they like or dislike. One of the care plans viewed was for a person that was admitted to the home with pressure sores and leg ulcers. The records included an up to date wound Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 11 care assessment and detailed care plan. The records provided clear information about the appearance and size of the wounds, the type of dressing that staff were applying and the frequency of dressing changes. The records indicated that a Podiatrist and Tissue Viability Nurse had assessed some of the wounds. Pressure-relieving equipment was in use. A Tissue Viability Nurse visited the home once a month to provide advice and support for staff about the management of wounds and prevention of pressure sores. Staff said they found these sessions very helpful. Records showed that some residents were referred to other health care professionals such as the GP, Physiotherapist and Dietician. The inspectors spoke with three visitors and nine relatives provided written feedback about the service. Most relatives said they were informed about significant issues such as accidents and hospital admissions. 55.5 of relatives said the home was ‘always’ able to meet their family members needs, 11 of relatives said the home was ‘usually’ able to meet their family members needs and 33.5 of relatives said the home ‘sometimes’ met their family members needs. Two health care professionals provided written feedback about the service. The respondents said that most staff had adequate skills and experience to meet people’s needs and staff usually respected people’s privacy and dignity. One person said that there had been a problem in the past with the attitude of some members of staff but this had been addressed. The other person said that staff required more training to meet the needs of people with complex needs. A CSCI pharmacy inspector carried out an unannounced inspection to assess the management of medication on 23/05/07. The pharmacy inspector’s findings are outlined below. One requirement from the previous inspection was assessed and was found to be partially met because staff were not recording the quantity of medication that was carried forward from the previous months supply. See requirement 1. Some improvements had been made such as purchasing additional medication trolleys. The clinical rooms were in good order, the manager had carried out internal medication audits and the supplying pharmacy had provided medication training for staff. Most receipt records and all returns records were accurate however there were still issues with administration records, which could place residents at risk. On one unit, the instructions on the medication administration record (MAR) charts Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 12 for ten residents were not complete. The charts stated: “As directed”. In some cases, staff had not administered any medication, as they were unsure of the dose/frequency. See requirement 2. For one resident, there were 8 missing signatures for a sleeping tablet and for another resident, 7 missing signatures for an antidepressant. On checking the stock, these medicines had been given, but staff had omitted to sign the MAR chart. For another resident, medication had not been given on several occasions and there was no explanation why. See requirement 3. There was one controlled drug in stock, which had not been used for some time and no stock checks had been carried out since January 2007. See requirement 4. Although staff were recording the temperature of the medication fridges, one medication fridge had been reading 13 degrees centigrade for several weeks and no action had been taken. See requirement 5. Some other recording issues were noted such as changes to the dose and frequency of administration had been made but staff had not signed or dated the changes, there were no running totals of homely remedies, checks on a resident that was self-administering had not been carried out since February 2007 and information about allergies was not recorded for all of the residents. Some of the care plans seen by the inspectors included guidance for staff about maintaining people’s privacy and dignity. For example one care plan stated that staff should ask the resident to choose their own clothing and encourage them to take part in their own personal care. One resident on Epsom told the inspector that they liked to get up at 10:00am and have a late breakfast. Staff were following the persons preferred routine. Charlton Park Care Centre DS0000068284.V338150.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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a regular programme of activities but some people did not receive adequate support to take part in the sessions and did not have an opportunity to go out. The visiting arrangements were satisfactory and most people said they enjoyed their meals. EVIDENCE: The home had one full time activity coordinator. The coordinator had spent time observing and talking to the activity staff in another home but had not received any formal activity training. The activity coordinator was well motivated and enthusiastic but received little support from care staff. A number of residents required ‘one to one’ support to take part in group activities. The activity programme was displayed. The programme included bingo, dominoes, music and movement and an art class. The coordinator said the programme was changed if residents expressed an interest in other activities. Activity records were maintained for each person. There was evidence that activities were taking place regularly although there were some gaps in recent months when the activity coordinator was asked to work in the Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 14 kitchen. The records indicated that people that required a lot of support did not have regular opportunities to take part in group activities. The mini bus was now ready for use and the activity organiser had recently attended a bus safety training session. There had not been any outings in the period since the last inspection. The results from a recent survey showed that some relatives were not satisfied with the provision of activities in the home and community. See recommendation 1. Relatives said they were able to visit at anytime and were always made to feel welcome. A relatives meeting had taken place in April 2007 to explain about the management changes. Three relatives were not aware that there was a new manager in post. The manager should ensure that minutes are sent to any relatives that cannot attend the meetings. Lunch was observed on both units. The current menu was not displayed on the ground floor unit and some residents could not remember what they had chosen for lunch. Staff wore aprons when they were serving lunch and when they were assisting residents to eat. As there were a number of residents that required assistance all of the staff on duty including the trained nurses provided support during the lunch period. Food was nicely presented and pureed food was served separately to make it look more appetising. Residents had chosen their preferred dish from the menu on the previous day and were given the meal of their choice. The main dish (lasagne) was rather dry and some residents had difficulty cutting the pasta. All of the residents that were able to comment said they enjoyed the meal. Some relatives provided assistance at mealtimes and those spoken with said the food provided was generally satisfactory. The local authority had recently inspected the main kitchen. The standard of food hygiene was reported to be satisfactory. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were adequate procedures in place to manage complaints and to protect the people using the service. EVIDENCE: The complaints procedure was displayed in the reception area and was seen in some of the bedrooms. The home had received one complaint since the last inspection. The complainant raised concerns about a number of different issues all of which were investigated and responded to in a timely manner. Residents and relatives were familiar with the homes complaints procedure and said staff usually responded appropriately when they raised concerns. The home had an adult protection procedure and a copy of the local authority safeguarding procedure. Most of the staff spoken with had a good understanding of abuse and said they would report concerns to the manager or senior staff. One carer did not recognise the need to report concerns to senior staff and said they would take steps to investigate the matter themselves. One staff member was not familiar with the homes whistle blowing procedure. A protection of vulnerable adults training session was planned. The manager should ensure that the session provides clear guidance for staff about what they should do if they witness or are told about an Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 16 allegation of abuse and information about the homes whistle blowing procedure. The home had not made any referrals to the local adult protection team in the period since the last inspection. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained to a satisfactory standard. Infection control measures were good but care must be taken to ensure that all areas are kept clean. EVIDENCE: The home was maintained to a satisfactory standard but some of the internal decoration looked a little tired in parts. The paintwork in some of the bedrooms and the shower room on Epsom was chipped. The wall in bedroom 33 was damaged and the sluice room door on Epsom did not shut properly. The home had applied for a grant from the Department of Health to refurbish three of the bathrooms. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 18 The kitchens on each of the units had recently been refurbished and work to redecorate these rooms was planned. Some bedroom furniture had recently been replaced and new carpet and curtains were purchased for some of the communal areas. The home was found to be clean and tidy overall but one of the bedrooms on the ground floor was not maintained to a satisfactory standard. The cleaning records in the room indicated it had not been cleaned for two weeks. Hand washing facilities were good and anti bacterial gel was provided. The sluices were clean and tidy and clinical waste was stored appropriately. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were not always maintained. As a result some people did not receive their morning medication at the correct time. Staff had access to relevant training sessions and were supported to attain vocational qualifications. Adequate checks were not always carried out when recruiting new staff. This could compromise resident’s safety. EVIDENCE: Staffing levels were difficult to assess because there were three duty rosters for the trained staff, which were different in parts. One record included all of the registered nurses and there were two separate duty rosters for the two units, which also included the trained staff. Some of the trained staff were recorded as working on one of the documents, but not on the other roster and some staff were recorded as working on both units at the same time. Staff indicated there were occasions when there was only one trained nurse on duty on the ground floor unit. On the day of the inspection there were two trained nurses and four care staff on the ground floor. One carer was sick and another carer left without working the shift. Staff did not complete the 09:00 am medication round until 11:30 am. See requirement 6. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 20 Staff were polite and courteous but one resident said that care staff did not have time to talk. Two relatives, one of whom said, “other needs such as stimulation with conversation, human interaction are patchy”, also made this observation. The training programme indicated that staff would receive training about effective communication in 2007. The manager should consider moving this training forward 52 of care staff had a vocational qualification in care at level two and eight staff were due to commence this programme in 2007. Three staff files were examined. None of the files fully complied with regulations. Some of the information that was missing from the files included a recent photograph of the employee, an explanation about gaps in employment and proof of registration with the Nursing and Midwifery Council. Some of the references were not on headed paper and were not verified. See requirement 7. The registered company has a dedicated training department and a programme of training was developed for each region. A record was maintained about the training sessions that staff had attended. The manager should consider maintaining individual records for each member of staff. This would make it easier to establish when mandatory training updates were due. Since the last inspection some staff had attended infection control, moving and handling, fire safety, tissue viability and care procedures training sessions. Seventeen staff had recently enrolled on a dementia care course with Bromley College and one member of staff had completed a moving and handling trainers course. Staff were satisfied with the amount and quality of training provided and a number of care staff expressed an interest in completing a vocational qualification at level three. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager had completed his induction and was starting to familiarise himself with the home. Procedures were in place to monitor and address health and safety issues and to safeguard people’s money. There were systems in place to monitor the quality of care provided in the home but this information was not always made available to the people using the service. EVIDENCE: A new manager had been appointed since the last inspection. The new manager had been in post for just over two weeks at the time of this Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 22 inspection. The manager said he had a nursing qualification, a PHD in health information and had experience of managing care homes for older people. The manager was aware of the procedure to register with the commission and had obtained an application form. The new manager had started to familiarise himself with company procedures and had read the last inspection report. All of the files in the office were being reviewed and reorganised to ensure that information could be easily located. There was a system in place to review the quality of care provided in the home. This included an annual satisfaction survey, a regular programme of audits and a comprehensive annual audit that assessed compliance with the national minimum standards. The results from the satisfaction survey that was undertaken in December 2006 was not available in the home. Some relatives had requested feedback from the survey during a recent meeting. See requirement 8. The new manager had carried out some unannounced visits to meet the night staff and to monitor care practices. Adequate procedures were in place to safeguard resident’s money. Individual records were maintained about money handed to staff for safekeeping or returned to the resident. Receipts were kept for all purchases made on the resident’s behalf and for payment of services such as chiropody and hairdressing. Fire safety records were satisfactory but it was not always clear from the records what time the drills had taken place or how staff had responded. See recommendation 2. Health and safety records were sampled. All of the records seen were satisfactory but the gas safety certificate could not be located. See requirement 9. Accidents records were examined on each unit. The information recorded was mostly satisfactory but some forms did not state the time of the accident. See requirement 10. There was some evidence that staff were starting to analyse accidents and consider what action they could take to protect the resident. Most of the rooms had an adjustable height bed with built in bedrails. The files that were seen for residents that were using bedrails included an up to date risk assessment. The maintenance employee had attended bedrail training and carried out regular checks to ensure equipment was fitted properly and in good working order. Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 Requirement The Registered Person must ensure that staff record medication that is carried forward from the previous month on the MAR chart. The Registered Person must ensure that all prescribed items have full instructions for use on both the MAR chart and the dispensed container. The Registered Person must ensure that all medicines administered are signed for at the time of administration or an explanation given. The Registered Person must ensure that all stocks of controlled drugs are checked on a regular basis even when not in regular use. The Registered Person must ensure that all medication is stored at the appropriate temperature. The Registered Person must ensure that adequate staff are provided on all shifts and that the off duty roster provides an accurate record of the staff that DS0000068284.V338150.R01.S.doc Timescale for action 07/08/07 2. OP9 13 07/08/07 3. OP9 13 07/08/07 4. OP9 13 07/08/07 5. OP9 13 07/08/07 6. OP27 18 07/08/07 Charlton Park Care Centre Version 5.2 Page 25 7. OP29 19 8. OP33 24 9. 10. OP38 OP38 23 17 worked in the home. Restated requirement, as the previous timescale of 11/04/07 was not met. The Registered Person must ensure that adequate checks are carried out and documentation obtained before staff are permitted to work in the home. Restated requirement, as the previous timescale of 25/04/07 was not met. The Registered Person must ensure that the findings from satisfaction surveys are shared with residents and their representatives. The Registered Person must ensure that gas appliances are serviced regularly. The Registered Person must ensure that accident records include the time of the accident. 07/08/07 04/09/07 04/09/07 07/08/07 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 OP12 Good Practice Recommendations The Registered Person should ensure that: • The activity coordinator receives formal activity training • The number of activity hours are increased • The person in charge allocates one member of staff to assist with activities each day The Registered Person should ensure that fire drill records state the time of the drill and indicates how staff responded. The Registered Person should ensure that care staff receive formal supervision at least six times a year. 2. 5. OP38 OP36 Charlton Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Park Care Centre DS0000068284.V338150.R01.S.doc Version 5.2 Page 27 - 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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