Inspection on 10/08/06 for Charnwood

This inspection was carried out on 10th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Charnwood 23/04/07

Charnwood 18/01/06

Charnwood 16/09/05

Charnwood 07/01/05

Charnwood 03/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Charnwood Charnwood 7 Finchfield Road Finchfield Wolverhampton West Midlands WV3 9LS Lead Inspector Mr Ian Harris Key Unannounced Inspection 10th August 2006 08:00 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 Charnwood DS0000020883.V297481.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. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood Address Charnwood 7 Finchfield Road Finchfield Wolverhampton West Midlands WV3 9LS 01902 424579 01902 565522 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) Caram (CHWD) Ltd Mrs Krishna Devi Ram Care Home 19 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (19) of places Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All DE category service users must be accommodated on the ground floor. The agreed staffing levels are: 8am - 9pm Senior Carer 2 care staff Night staffing 2 waking care staff Care Manager hours are supernumerary Separate catering/domestic/laundry staff/activity organiser must be provided in addition to care hours. These are minimum staffing levels - and must be increased in the event of any increase in dependency of service users accommodated. CSCI will continue to monitor the staffing levels and may require levels to be increased should CSCI feel that care needs are not being met. All care staff must complete the agreed training programme before March 2006. Until such time as all staff have completed the required training, staff rotas must ensure that at least one member of staff that has completed the training is on shift at all times day and night. 18th January 2006 3. Date of last inspection Brief Description of the Service: The home is a large, detached property, which is approximately 77 years old. The home is situated in a pleasant residential area and overlooks Bantock park. There is easy access to all the local amenities. The home accommodates 19 service users in single bedrooms. Nine of the bedrooms have en-suite facilities. There are three separated sitting rooms and a dining room. There are pleasant gardens at the rear of the building. There are two bathrooms with hoists. The third bathroom/shower/WC is not suitable to be used by the current service users. The WC in this bathroom is also used by the staff. There are adequate WCs facilities in the home. There is a kitchen, laundry room and an office. At present, there is no staff accommodation and personal storage facilities for individual members of staff. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5. hours. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 4 members of staff and 6 residents were spoken to. It was noted that the fees range between, £336 to £395. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken to who could express themselves in a meaning full way expressed their satisfaction with the home and the care they receive. “ We are all very happy here we’ve got company” “ It’s like a family hear” “ The staff look after us very well ” were some of the comments made. What the service does well: What has improved since the last inspection? The staffing has improved by the increase in care staff and the training programme has met previous requirements made in the inspection report. The home has implemented a quality assurance system to obtain views on the services provided and has addressed comments and suggestions made by residents and relatives. There has been and improvement in the residents files and care plans which ensures residents needs are being monitored and met. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 6 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. Charnwood DS0000020883.V297481.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 Charnwood DS0000020883.V297481.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Four care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication in not good and residents could be at risk. The quality outcome in this area is poor. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Six residents case files were inspected and all contained a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the Care Plans are being carried out and reviewed on a monthly basis. Medication is administered by means of a monitored dosage system. However Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 10 this system is not being used properly. Drugs are being transferred from the Dosset boxes into a pots and taken to the resident. This is secondary dispensing and must stop. It was also observed that drugs were being left with residents and not witnessed that they were taken. Staff were giving out the drugs to all the residents’ and then filing in the record sheets in the office. The record sheet should be filled in at the point when the resident takes or refuses medication. It was note that the drugs are stored in a cupboard in the entrance hall. The provision of a drugs trolley that can be stored in the office and used to take the drugs to the resident would be a great improvement. All residents have single rooms. No personal care interventions take place in communal areas. Observed practice on the day of inspection was appropriate and showed respect for the residents. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the quiet lounge on the ground floor offers that privacy when not being used Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 The home provides a stimulating experience for the residents where they are encouraged to maintain their independence as much as possible The home provides a good range of social activities within and outside the home designed to the capabilities of the residents The meals in the home are good offering both choice and variety and also catering for special dietary needs. The quality outcome in this area is excellent. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. There was also evidence to show staff do consult with the residents regarding the choice of meals and activities within the home. For residents with communication problem this is done by the keyworker. The key-worker also identifies interests that the residents wish to pursue. A regular programme of musical entertainment, Art and Craft sessions, board- games, keep fit and sing-a-longs is organised within the home. There is a designated member of staff who has responsibility for organising social activities. In regards to outings there has been a theatre trip Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 12 and a canal boat trip. In the good weather residents are taken to Bantok park on a regular basis. The observations made, examination of menus and the comments received from the residents and the relative’s representative confirmed that particular attention is given to the residents’ individual preferences. Comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies regarding protection from abuse, which includes a whistle blowing policy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a good complaints procedure and all complaints are recorded in a, complains book. Residents and their families are given a copy, of the complaints procedure at admission and there are copies readily available in the home. It was noted that no complaints have been recorded since the last inspection. However it was noted, in the passed minor complaints have been dealt with quickly and appropriately. The home has good policies and procedures in place regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which includes, a Whistle-Blowing policy. These issues are also covered in the induction, N.V.Q. training, and internal training. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The general standard of the environment is good providing service users with a homely, comfortable and safe place to live. The good standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is long established and has great character and undergone alterations over the years in order to provide appropriate accommodation for 19 older people. The home is maintained to a very high standard, as are the gardens and grounds and provides a very comfortable homely and safe atmosphere. It was noted that the following area should be prioritized, the corridors by the kitchen and lift need redecorating and the floor covering replaced also the back staircase carpet needs replacing. All the recommendation and requirements from the last inspection have been met Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 15 apart there is no staff room or suitable storage facilities available in the home for staff to store their personal belongings. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the residents support needs. The home has good policies and procedures regarding the recruitment of staff. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: There has been a improvement in staffing since the last inspection and the inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The home operates an acceptable recruitment procedure and has registered with the Social Care Association in order to complete the appropriate checks on staff. On inspecting 6 staff files, there was evidence within them that all the checks are being carried out. The Care Manager and staff are committed to developing their knowledge and skill through training. The home has a very good induction programme and training programme. In addition to the N.V.Q. 2, 3 and 4 training programme the Manager and Deputy Manager has the Registered Managers Award. Also all of the care staff have attended training courses on the following subjects. Safe handling of medication, Risk assessment, Dementia care, Manual Handling, First- Aid, Infection Control, Dementia Care level 2 and Fire Prevention and Health and Safety. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. The home is a well managed, where service users interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the general records that were inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is well managed by the Care Manager who is qualified in both practice and management and has considerable experience in caring for older Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 18 people in residential homes There are clear lines of accountability within the home and is very supportive of both staff and residents. Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and service users who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. Discussions with the chair of the Residents Association who meets with the relatives of the residents on a regular basis confirmed that the home was very well run and all the staff are approachable. There is a good staff supervision system in place and there is evidence that the staff have regular supervision meetings. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents regarding the choice of meals and activities within the home using photographs where necessary and this was confirmed by the residents who could express themselves in a meaningful way. There are regular residents and relatives meetings where residents are consulted about menus and entertainment etc. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 19 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 20 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 OP20 Regulation 23 (3)(a) Requirement The Registered Providers must provide suitable facilities and accommodation for the purpose of changing and storage facilities for the staff employed in the home. The Registered Person must ensure that the monitored dosage system is used correctly and that secondary dispensing is stopped. Also that staff witness the taking or refusal of medication and then record it at that point. The Registered person must ensure that the corridors by the Kitchen and lift are redecorated and the floor covering replaced. Also the carpet on the back staircase is replaced. Timescale for action 01/04/07 2 OP9 13 (2) 01/09/06 3 OP19 23 01/11/06 Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Charnwood DS0000020883.V297481.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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