Inspection on 19/12/07 for Charlton Park Care Centre

This inspection was carried out on 19th December 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 11/06/07

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 19th December 2007 09:50 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.V353256.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.V353256.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.V353256.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 11th June 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.V353256.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two key inspections that the Commission for Social Care Inspection (CSCI) carried out in this home in 2007. A number of concerns were identified during the previous inspection and the provider was asked to provide an improvement plan to show how they would address the requirements that were made. This inspection took place on 19/12/07 between 9.15am – 5.35pm and was unannounced. Two inspectors spent the day in the home observing care practices, examining records and assessing the effectiveness of the homes improvement plan. During the inspection the inspectors spoke with six residents, four relatives and nine members of staff. A CSCI pharmacy inspector carried out an unannounced inspection on 28/12/07. 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 and used the information to develop a care plan. Written information about the service was provided and people were told about their rights and responsibilities. People were able to choose how and where they spent their time in the home. Relatives were satisfied with the visiting arrangements and said that they were able to visit their family member when they wanted. The choice of food provided was good and most people said they enjoyed their meals. Complaints were investigated and responded to in a timely manner. CSCI and Social Services were advised about significant events and allegations. Staff could attend regular training sessions and were supported to gain qualifications. The building was maintained to a satisfactory standard and fire safety arrangements were good. All areas were clean and tidy. Personal money and valuables were stored securely and up to date records were maintained. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Record keeping had improved but further work was required to meet some standards in relation to this issue. Staff did not always identify people’s social needs or provide adequate information about the support they provided. It was not always clear who changed information on medicine charts or when changes were made. Staff completed accident and incident forms but did not always include information about injuries or state if the person required medical attention. Some activities were taking place but they did not always meet people’s needs and expectations. Some people said there was not enough to do and they wanted more outings and trips. Staff must ensure that residents are supervised at mealtimes and receive assistance to eat. This will ensure that food is hot and that people receive adequate nourishment. Staffing levels had improved but further work was required to maintain suitable staffing levels during periods of staff sickness and absence. This will Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 7 reassure people that there will always be adequate staff on duty to meet their needs. Some members of staff did not take adequate care when they were assisting people to move. This could compromise people’s health and safety. 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.V353256.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.V353256.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): 2 and 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. Staff carried out a care needs assessment before confirming if the home could meet people’s needs. Assessments included adequate information about medical problems but did not always identify people’s social needs or interests. EVIDENCE: Staff assessed and recorded information about peoples care needs and likes and dislikes. The assessment was carried out before the person moved into the home. Two pre-admission assessments were examined on each unit. Information about people’s medical problems, mobility and communication was good but the section about people’s social needs and interests was incomplete on two assessments. Records showed that staff obtained written information about the person’s needs and medical history from the funding authority and other professionals. See recommendation 1. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 10 The contract provided information for people about their rights and responsibilities. The contracts for two people that lived on the ground floor unit were examined. The agreement was kept in the main office and was agreed and signed by the resident or their representative. Charlton Park Care Centre DS0000068284.V353256.R01.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided guidance for staff about the action they should take to meet people’s physical needs but often included little detail about people’s social needs and interests. Staff will not be able to provide holistic care if they do not have adequate information about the people they are supporting. The management of medicines had improved. Adequate systems were now in place to maintain resident’s safety and wellbeing. EVIDENCE: Two care plans were examined on the ground floor unit and three on the first floor unit. Although some work was required to meet standard 7, information that was recorded about peoples needs had improved and some of the care plans seen were very detailed. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 12 Care plans were developed to meet people’s health and personal care needs but did not always acknowledge that people required support to meet their social needs. For instance one care plan provided detailed information about the type of assistance the person required at mealtimes, with toileting, to prevent pressure sores and to move but did not state how the person liked to spend their time or what activities they enjoyed. See requirement 1. Apart from toileting, the inspector was able to see that staff on the ground floor unit were following the guidance that was recorded in the care plan. The care plans for people that lived on the first floor unit were good. Plans referred to peoples individual preferences such as sleeping in the chair and listening to the radio but it was not always easy to establish if the care plan was followed. For instance one plan stated that a resident liked to have a bath or shower three times a week. The daily care records did not indicate if this was taking place and the resident was not able to provide any feedback about this issue. See requirement 2. Care plans provided guidance for staff about maintaining people’s privacy and dignity. On plan was seen for a person with multiple sores. Records and photographs provided information about the appearance and grade of the wound and the dressing regime. Advice was obtained from the Tissue Viability Nurse and Dietician and pressure-relieving equipment was in use. Care plans were reviewed regularly and were usually discussed and agreed with residents or relatives. One person had developed difficulty with toileting. This was monitored by staff and was dealt with in a way that preserved the dignity and independence of the resident. The resident concerned confirmed their involvement in the formulation of the care plan and was happy with the support they were receiving. People were weighed regularly and where necessary care plans were developed to monitor weight loss and food and fluid intake was monitored. Staff obtained advice from the GP or Dietician if people were not eating or were losing weight. The records showed that staff were identifying nutritional problems and seeking advice and support from other professionals much more quickly than they had in the past. Records showed that health care professionals such as the GP, Psychiatrist, Optician, Physiotherapist and Chiropodist visit the home regularly. Residents and relatives said that call bells were answered promptly. A pharmacy inspector carried out a medication inspection on 28/12/07. Medication records for all residents and medicines stocks and storage were inspected. The management of medicines had improved since the last inspection. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 13 All records were completed accurately, all medicines were in stock and records showed that residents received their medicines on time, and as prescribed. Two amendments on medication charts were not dated and initialled by the member of staff that made the change. See recommendation 2. Risk assessments were in place and were reviewed regularly for residents that managed their own medicines. Staff entered the administration code “F” on the medication chart for residents that were self-administering. This is not necessary. Staff should make a general statement on the medication chart that the person is self-medicating and only need to make further entries on the chart if stocks or compliance are checked. See recommendation 3. Controlled drugs were stored safely. Staff that were responsible for administering medicines had attended two medication training sessions from an external source and Four Seasons ‘inhouse’ training since the last inspection. Staff completed a formal assessment to ensure that they had adequate skills and knowledge to support people to take their medicines. The Manager had met the GP and the Pharmacist to discuss the management of medicines and to ensure that prescriptions and supplies of medicines were received on time. Arrangements had been made for a back-up pharmacy to supply medicines in emergencies. The home was carrying out regular audits of medication handling and records. These were effective in picking up and addressing issues. Charlton Park Care Centre DS0000068284.V353256.R01.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some activities were taking place but they did not always meet people’s individual needs and expectations. Most people said they were satisfied with the choice and quality of food provided in the home but staff did not always identify people that required additional support. EVIDENCE: The activity coordinator was employed for 30 hours per week but was due to go on leave for a period. Plans were in place to appoint a temporary activities person in the activities coordinators absence. Since the last inspection the home had recruited a new part time activities person. This person provides regular musical entertainment. The activity programme was displayed on the notice board near reception. The programme was positioned out of most residents view. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 15 It was difficult to establish if the home was able to meet people’s individual social needs as care plans provided little information about people interests and hobbies and activity records were often incomplete or blank. Staff must ensure that adequate information is recorded so that activities can be properly targeted to meet people’s different needs. See requirement 3. Residents and staff confirmed that there were regular exercise classes and musical entertainment. The activities person had not received any formal activity training but the manager said this was planned for January 2008. See recommendation 4. The home has a tail lift vehicle for use by residents. Two residents and two relatives expressed concerns about activities and said they felt there should be more opportunities to go out in the minibus. Relatives said they were able to visit at anytime and were always made to feel welcome. A relatives meeting was held in November 2007 and another meeting was due to take place in February 2008. The home had developed a bi-monthly newsletter. ‘The Chatterbox’ provides general information for residents and relatives about events that are taking place in the home, staff changes and feedback from meetings and surveys. Records indicated that resident’s wishes were respected and people said they were able to choose where they spent their time. The daily care records for one person stated they refused to go to bed. As staff could not persuade the person to go to bed they placed the person in a comfortable chair near the nursing station where they could be monitored and made them some tea and toast. Lunch was observed on two units. Residents said they were able to choose what they wanted to eat from the menu and could request alternatives if they did not like any of the options listed. The food looked appetising and was hot. Most residents said they enjoyed their meal. Juice and napkins were provided but condiments and sauces were not offered or placed on the tables on Epsom. Staff assisted people that had difficulty cutting their food or eating independently but this was not completed in a timely manner for one person on Epsom. The meal was placed in front of this person and they were left to eat independently. After fifteen minutes a member of staff noticed the resident was not eating and placed their meal in the heated trolley. Requirement 4. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had procedures in place for investigating concerns, complaints and allegations. EVIDENCE: The complaints procedure was displayed in the main reception area and there was a summary of the procedure in the ‘Service User Guide’. The home had received two complaints about care issues since the last inspection. The manager investigated the complaints and a formal response was sent to social services. The findings from one investigation indicated that staff did not always maintain adequate records. The commission was notified about significant events that occurred in the home such as accidents and allegations. The manager notified social services about an unexplained injury and with their agreement investigated the circumstances and cause of the injury. This issue will be dealt with under the homes disciplinary procedure. The home had an adult protection procedure and a copy of the local authority safeguarding procedure. Staff had a good understanding of abuse and said they would report concerns to the manager or senior staff. Some staff said Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 17 they had recently attended adult protection training and had found the session very helpful. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a comfortable environment for the people using the service and their visitors. EVIDENCE: All of the communal areas and a selection of bedrooms were inspected. All parts of the home were clean, tidy and free from unpleasant odours but some of the chairs in the lounge on Epsom were damp as a result of cleaning. Replacement chair covers should be purchased if there is not adequate time for the covers to dry overnight. The building was maintained to a satisfactory standard and regular health and safety checks were carried out to ensure that equipment was working and safe Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 19 for use. The wall surface in room 33 was damaged and the toilet seat was missing in the shower room on Epsom. See recommendation 5. Some of the bathrooms were congested. There was a medicine trolley, three hoists and a linen trolley stored in one of the bathrooms on Epsom. Staff should ensure that all areas are accessible. Some of the paintwork in the bathrooms was worn and chipped in parts. Plans were in place to refurbish four bathrooms using funding from a Department of Health grant. All of the areas visited were warm and no concerns were raised about the temperature in the home. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Staffing levels had improved but further work was required to maintain suitable staffing levels during periods of staff sickness and absence. Staff received regular training updates and support to gain recognised qualifications. Thorough checks were carried out when recruiting new staff. This protects people that use the service. EVIDENCE: The current off duty roster was examined. There were separate rosters for each unit and information was easy to follow and read. Changes were crossed out with a single line. The roster showed that staffing levels had stabilised following the appointment of some new staff. On the day of the inspection one carer was absent on Epsom. This left two trained bank nurses and five care staff to care for 30 people with dementia. A number of people on this unit have challenging behaviour and high care needs. Efforts were made to replace the carer but this was unsuccessful. One member of staff spent part of her first day in the lounge, supervising residents. This staff member was aware that she must not complete any moving and handling tasks but had very little knowledge about the people she was caring for. Although the majority of transfers seen were Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 21 satisfactory two people were moved from a chair to a wheelchair without proper checks being undertaken. The manager witnessed one of these transfers and discussed the issue with the staff involved. Some of the staff on this unit said they were not able to have a proper tea break because they were so busy. See requirement 5. There were two qualified nurses and five care staff on the ground floor unit. The staff on this unit said staffing levels had stabilised in recent weeks due to the appointment of some new bank and permanent staff. Although this unit was busy staff had adequate time to talk to people. The home met the standard set by the Department of Health for 50 of care staff to attain a recognised care qualification. Three staff recruitment files were examined. Information was easy to locate and was well organised. The files included evidence that all of the necessary documents and checks including two written references and criminal record bureau disclosures were undertaken. An interim protection of vulnerable adults (POVA first) check was obtained for one member of staff and the manager confirmed that the staff member was working under supervision. Staff said they received adequate support and training. Since the last inspection some staff had attended adult protection, induction and moving and handling training sessions. Training records were maintained but were difficult to follow in parts as information was not in order or indexed. Interactions between staff and residents on the top floor unit had improved. One member of staff accidentally dropped a person’s tablets. The resident was told what had happened and reassured that replacement tablets would be obtained. A new member of staff demonstrated good communication skills and empathy for a resident who was confused about where she was and what she should be doing. Twelve staff had attended customer care and communication training since the last inspection. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This service had improved but concerns were identified about record keeping and moving and handling practices. The service will not be able to demonstrate that it provides good outcomes for residents if records are not properly completed. There were good systems in place to monitor health and safety issues and to safeguard resident’s money. EVIDENCE: The manager has a nursing qualification and a PHD in health information. The manager had previous experience of managing registered care homes for older people. The manager was assessed and registered by the commission for social care inspection in December 2007. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 23 A number of improvements were noted during this inspection and most of the previous requirements had been addressed. However concerns were identified about some aspects of record keeping and moving and handling practices. These issues must be addressed. The findings from a recent satisfaction survey were included in the homes newsletter. Relatives and residents could request a copy of the full report if they wanted and were asked to make suggestions about how the home could improve certain aspects of care such as ironing and outings. Adequate procedures were in place to safeguard resident’s money. Individual records were maintained about money given to staff for safekeeping or handed back 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. A financial audit was due to take place in January 2008. Work was in progress to provide regular supervision for staff. Although some staff said they had received supervision, records showed that it did not always take place at regular intervals. Supervision records were maintained but did not always provide feedback about issues that were discussed during the previous meeting or state when the two staff members would meet again. See recommendation 6. Fire safety arrangements were good and information about fire drills had improved. The maintenance technician carried out regular checks to identify hazards and to ensure that equipment was safe for use. A copy of the current gas safety certificate was sent to CSCI. Four accident forms were examined. Two forms were properly completed but the remaining forms did not include adequate information about injuries or state if the person required any treatment. For instance one person sustained a cut as a result of a fall. The accident form did not provide any information about the size or depth of the cut. Another form provided information about an incident involving a staff member. It was not clear if the staff member was injured or required any treatment. See requirement 6. The previous requirement to record the time of accidents and incidents was met. Staff provided assistance to walk and move. Most people were moved carefully and received adequate information. However some of the staff on Epsom appeared rushed during the lunch period and did not always take adequate steps to maintain peoples safety. Staff assisted two people to move before checking that equipment was properly positioned and safe for use. The manager observed one of these transfers and discussed the issue with staff. See requirement 7. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 24 Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Person must ensure that care plans state the action that staff should take to meet people’s social needs. The Registered Person must ensure that records show that care plans are followed and people’s needs are met. The Registered Person must ensure that regular activities are provided to meet people’s individual needs and interests. The Registered Person must ensure that residents receive prompt assistance to eat. The Registered Person must ensure that adequate staff are provided to meet peoples needs. This requirement was revised. The Registered Person must ensure that that staff record information on accident forms about injuries and state if the person required medical treatment. The Registered Person must ensure that all staff follow safe moving and handling procedures. DS0000068284.V353256.R01.S.doc Timescale for action 01/05/08 2. OP37 17 01/05/08 3. OP12 16 01/05/08 4. 5. OP15 OP27 12 18 03/04/08 03/04/08 6. OP38 17 03/04/08 7. OP38 13 03/04/08 Charlton Park Care Centre Version 5.2 Page 27 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. 3 4. 5. 6. Refer to Standard OP3 OP9 OP9 OP12 OP19 OP36 Good Practice Recommendations The Registered Person should ensure that the care needs assessment includes information about people’s social interests and hobbies. The Registered Person should ensure that changes to medication charts are signed and dated by the person amending the record. The Registered Person should ensure that staff record ‘self-medicating’ on the medication chart when a person is managing their own medicines. The Registered Person should ensure that activity staff receive relevant training. The Registered Person should replace the toilet seat in the shower room on Epsom and repair the damaged wall surface in room 33. The Registered Person should ensure that care staff receive formal supervision at least six times a year. Charlton Park Care Centre DS0000068284.V353256.R01.S.doc Version 5.2 Page 28 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. 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