Inspection on 18/05/07 for Charnley House

This inspection was carried out on 18th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charnley House 09/01/06

Charnley House 03/08/05

Charnley House 21/02/05

Charnley House 20/09/04

Charnley House 03/03/04

Similar services:

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Charnley House Albert Road Hyde Tameside SK14 1DH Lead Inspector Janet Ranson Unannounced Inspection 18th May 2007 09:30a 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 Charnley House DS0000005564.V337058.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. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnley House Address Albert Road Hyde Tameside SK14 1DH 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) 0161 368 4664 0161 368 7073 care@charnleyhouse.co.uk Charnley House Limited Mrs Lynda Elizabeth Lanceley Care Home 41 Category(ies) of Dementia - over 65 years of age (41), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (41), Physical disability over 65 years of age (41) Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 41 service users to include: *up 41 service users in the category of OP (Old age not falling within any other category). *up to 41 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 41 service users in the category of DE(E) (Dementia over 65 years of age). *up to 1 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th January 2006 2. Date of last inspection Brief Description of the Service: Charnley House is a large, detached building located close to the centre of Hyde. The property has been adapted and extended over the years to provide accommodation for 41 older people, some of whom can have dementia, physical disabilities, sensory disability or mental health problems. The latest extension was completed in November 2005 when additional en-suite bedrooms and communal areas were provided. The accommodation is situated on three floors; there are 37 single and two shared rooms. 16 single rooms have en-suite facilities. In total there are 5 communal areas of differing sizes in addition to a conservatory. One lounge is currently provided for those people who choose to smoke. A dining room is located on the ground floor close to the kitchen. The home provides aids and adaptations to meet individual needs and there is a full passenger lift. Car parking is to the front of the building and there is a secure garden to the rear. Fees for accommodation and care at the home range from £343 to £384. Additional charges are also made for hairdressing and chiropody services, newspapers, personal toiletries and trips. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key inspection, which included an unannounced site visit. The site visit took place on 18th May 2007 and covered a period of eight and a half hours from 09:30 until 18:00. The home had completed a pre inspection questionnaire that gave the inspector certain information about the service. During the site visit time was spent talking to the residents, some of the care staff, the registered manager and the district nurse. A total of five visiting relatives also assisted the inspector with their comments. The inspector looked the home’s routine and how the staff worked and talked with the residents. A total of four residents identified needs were closely looked at. Individual details of their experiences and care were examined from when they first came into the home to their current care needs. The inspector looked around the building. A selection of staff and residents’ records was examined. A relative told the inspector that, “Charnley House is a home not an institution.” Another visitor said they were beginning to feel part of a “large family.” What the service does well: What has improved since the last inspection? Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 6 A new patio garden is being created to the side of the building. This area will be fully accessible from the conservatory and will be in addition to a patio area located on the lower ground floor. The practice of using correction fluid in the medical administration records has been stopped. 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. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Standard 6 Intermediate care is not provided at Charnley House. Quality in this outcome area is good. Systems are in place to ensure the residents’ needs can be fully identified and met by the home. Prospective residents and their representatives are able to visit the home in order that they can assess the service for themselves. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care needs assessments were contained within the four care files examined as part of the inspection. Charnley House also uses a system of assessing the potential resident’s needs that is carried out by a senior member of staff. By completing such an assessment the home can ascertain individual needs and ensure they can be met. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 9 A resident’s relative stated that they had been invited by the manager to visit the home with the potential service user to see the vacant room and other communal areas for themselves. A further relative said that the friendly welcome they received from the staff during their visit assured them that their relative would be safe and feel at home at Charnley House. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. The care planning process identifies the residents’ individual health and social requirements. They provide the carers with action to be taken to provide appropriate care on a day-to-day basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were examined as part of the inspection process. They set out the residents’ individual personal care needs and were based on the initial assessment. The care plans document the action to be taken by the carers to ensure all aspects of health, personal and social care are met and reviewed. The information was not well organised and some of the pre-printed documents were loose and could have been mislaid. The current system is too generalised and it is recommended that the home starts to look at how they can replace it with a plan that puts the individual at the centre. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 11 In particular a personal social history would benefit the carers to better understand a resident especially those with dementia. This was discussed with senior staff and the manager. Where identified, the resident’s health is monitored and addressed by the appropriate health care professionals. The district nurses are involved on a regular basis as are the chiropodist, audiologist, dietician and speech therapist. The district nursing team had recently been changed. The new district nurse had raised concerns with the Commission for Social Care Inspection about certain aspects of care. She had been advised to raise them with the registered manager. A discussion with the manager, the inspector and the district nurse took place during the inspection. The manager had addressed some of the issues and agreed to have regular meetings with the district nurse in order that the residents’ medical needs would be appropriately met. At Charnley House the senior staff are responsible for the administration of medication. There was evidence to show they had received training to correctly administer medications. Records are retained to show changes to medications and medical interventions. The home uses a monitored dosage system provided by a local pharmacy. The local pharmacy also provides the medical administration records (MAR). The medication storage and observed practice was satisfactory. Based on observation, it was apparent that the staff respected the residents’ privacy by knocking and waiting before entering rooms. At interview the carers demonstrated their knowledge of individual needs and were observed to interact with them in a relaxed and informal manner. The inspector observed two carers supporting a resident who had limited mobility. They used a hoist to carry out the manoeuvre. It was apparent the carers were competent in the use of the equipment. At all times they ensured the resident’s dignity was preserved whilst assuring the resident of their safety. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. The choices offered to the residents meet with their requirements and needs and enable them to exercise elements of control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a small team of carers who plan, organise and carry out a programme of activities. Two of the workers are members of a professional activities organisation and have attended training courses provided by them. In addition there are two experienced people who attend the home at regular intervals throughout the week. They involve the residents in gentle exercises to music, reminiscence sessions and quizzes. There are regular entertainers and “karaoke” sessions provided by the staff. Photographs around the home provide evidence of “themed days” and of trips to places of interest. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 13 As previously reported the home does not document the residents’ previous lifestyles. It was acknowledged that the carers had learned either by observation or direct contact which residents did not enjoy certain activities. It was apparent from speaking to the carers that the residents’ relatives were well known and welcome to the home. From observation the visitors were at ease with the staff and the other residents. Visitors could be seen throughout the home during the inspection. There was plenty of lighthearted banter between the residents and the staff. A visitor described to the inspector how the staff had helped him feel part of his relative’s care. The main meal of the day looked appetising. Those residents who spoke with the inspector said they enjoyed the food and the choices available at each meal. The menus had been provided to the inspector prior to the inspection. The content appeared balanced and nutritious. The menu for the day is displayed in the dining room. A resident was observed to check the choice for the evening meal, which is the main meal of the day. The resident explained to the inspector the choice she had made and then went on to say the “food is very good here, I always enjoy my meals.” A visitor explained how her relative had lost weight whilst in hospital but was now putting it back on since he had been living at Charnley House. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system and that residents or their representatives feel their views are listened to and acted upon. Staff knowledge and understanding of adult protection issues provides a safe environment to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure concerning reporting and investigation of complaints. This is available to the residents in written form. The manager had recently received a formal complaint concerning the care of a resident. An investigation into the complaint had been carried out by the manager who then responded to the complainant according to the home’s procedure. The details had been forwarded to the inspector along with the disciplinary outcomes and had been retained on the record for inspection purposes. It was apparent that the manager had taken the complaint seriously and as a result certain care practices had been changed. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 15 As previously documented the district nurse had reported some care concerns to the inspector and the manager. It is to the manager’s credit that the concerns were considered and responded to in a manner that was conducive to improving the service and to continue working with the district nursing service. A relative told the inspector that she had had occasion to speak to the manager regarding aspects of care. She was satisfied with the professional manner in which she was received and speed in which her problem was resolved. The home has a policy and procedure to respond to allegations of abuse. The senior carers have received formal training in the Protection of Vulnerable Adults (POVA) as required. The carers have also received this training. They clearly demonstrated their understanding of abusive situations, when interviewed by the inspector. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26 Quality in this outcome area is good. Charnley House provides the residents and their visitors with a safe, warm and welcoming environment. Improvements to the grounds will benefit the residents in the better weather. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector looked around the home. It was observed that all areas of the home were clean, tidy and comfortable. It was obvious that the residents were encouraged to personalise their rooms with the presence of photographs, ornaments, books, pictures and furniture. All the bedrooms have been fitted with suited locks. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 17 It was noted there were aids throughout the home to meet with the residents assessed needs, including adapted toilets and bathing facilities. Specialist equipment to prevent pressure sores was in place where this need had been identified. The district nursing service had provided the equipment. It was evident that those residents who are independently mobile were able to move around all areas of the home at will. The registered person’s husband attends the home every day. He is responsible for basic maintenance and redecoration around the home. There appeared to be no outstanding maintenance requirements noted at this visit. A patio area was being created to the side of the home. It will be accessed from the conservatory and on completion will provide a second external area for the residents to sit in during the better weather. A team of domestic staff are employed at Charnley House to ensure the home is maintained in a clean and hygienic state. A resident told the inspector that her “bed was always clean and so is my bedroom.” Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. The residents receive care from an enthusiastic, well-trained staff who respond to the residents and visitors in a respectful manner. The homes recruitment policy and procedure provides protection to the residents from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation during the inspection the numbers of staff on duty met with the residents’ assessed needs. A rota was available for inspection and had been provided with the pre inspection questionnaire. It reflected the staff on duty at the time of the visit and showed a good deployment of staff during the waking working day. Further to this it provided time for the senior staff to handover duties and responsibilities at the start of each shift. According to the pre inspection questionnaire new staff had recently been recruited. The inspector chose to speak to a newly recruited carer. The carer impressed the inspector with his attitude and knowledge of his duties. He confirmed that he enjoyed all aspects of his role. He was hoping to get funding to carry out a National Vocation Qualification (NVQ) at level 3 having already completed level 2. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 19 A further interview was carried out with a carer. This person had completed an NVQ level 3 and was in the process of completing an accredited training course concerning dementia awareness at intermediate level. The staff have access to an impressive range of training courses in addition to the mandatory health and safety training. Training is considered to be important and the staff are encouraged to attend to ensure they have the necessary skills to meet the residents’ needs. The manager had confirmed no changes to the recruitment and selection procedures that had previously been inspected to a good standard. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. The manager of the home has the skills, experience and qualifications to run the home in the resident’s best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager, who is also the owner of the home, has the appropriate skills and experience to manage Charnley House where she has operated for several years. She has provided evidence to show she continues to supplement her knowledge and skills by continuous certified training. The home has a system to protect financial interests for those residents who are no longer able to deal with their money. Receipts are retained for any Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 21 expenditure made on behalf of those residents. The financial records were available for inspection. As previously noted elsewhere in this report, the quality of the care plans needs to be improved in order that they become easier for the staff to use as a working tool. The home uses part of a quality assurance system that is specifically designed for care homes purposes. Quality satisfaction surveys are sent out at six monthly intervals. The manager stated she responds personally to those surveys that need an acknowledgement. The passenger lift was being serviced during the inspection. There was further evidence to confirm the equipment and installations are maintained in working order through a series of service contracts. With one exception there were no hazards to health and safety noted. The exception was a small change in floor levels from the dining room to the conservatory that could lead to an accident. This was brought to the manager’s attention during the inspection. The health, safety and welfare are further ensured by the homes systems to report any accidents and incidents to the relevant authorities. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 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 Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The registered person should review the care planning process to provide more person centred approach. Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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 Charnley House DS0000005564.V337058.R01.S.doc Version 5.2 Page 25 - 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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