Inspection on 10/07/08 for Charnwood

This inspection was carried out on 10th July 2008.

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

Charnwood 07/07/10

Charnwood 22/02/10

Charnwood 01/12/09

Charnwood 17/08/09

Charnwood 08/04/09

Charnwood 06/12/07

Charnwood 16/05/07

Charnwood 22/05/06

Charnwood 19/10/05

Charnwood 03/05/05

Charnwood 20/09/04

Charnwood 19/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOMES FOR OLDER PEOPLE Charnwood 68 Bidston Road Oxton Birkenhead Wirral CH43 6UW Lead Inspector Jeanette Fielding Key Unannounced Inspection 10:00 10th July 2008 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 DS0000018873.V362750.R05.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 DS0000018873.V362750.R05.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood Address 68 Bidston Road Oxton Birkenhead Wirral CH43 6UW 0151 652 1984 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) sheila@charnwoodcarehome.co.uk Mr David Ashcroft Mrs Sheila Margaret Ashcroft Mrs Sheila Margaret Ashcroft Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 19 Date of last inspection 6th December 2007 Brief Description of the Service: Charnwood is a large, three storey detached house on a main road served by bus routes to Birkenhead town centre and other parts of Wirral. There are shops and other local facilities within walking distance of the home. Residents accommodation is in five single bedrooms and seven that are available for sharing. Two of the rooms are used as staff sleep-in rooms and are therefore not available for residents. The home has a shaft lift that provides access to all floors, including the basement/lower ground floor, which provides access to the garden and houses the owners’ accommodation, the office and the kitchen. Charnwood has a large combined communal lounge and dining room. The lounge is divided into a TV watching area and a quieter area nearer to the windows overlooking the spacious and attractive gardens. There is car parking at the front of the home. The fees for the home are between £346 and £395 per week. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use the service experience good quality outcomes. This unannounced key inspection was undertaken in one day over a period of six hours. As part of the inspection process, all areas of the home were viewed including many of the service users bedrooms. Assessments and care plans were inspected together with staff records and certification to ensure that health and safety legislation was complied with. Observation of the interaction between staff and people who live at the home provided evidence of the actual care given. Discussion took place with the manager, care staff, service users and visitors to the home. An AQAA (annual quality assurance assessment) was sent to the home to provide inspectors with information regarding staff, service users and the premises and was completed and returned in a timely manner. What the service does well: What has improved since the last inspection? What they could do better: The recruitment of staff needs to be addressed as a priority to ensure that service users are provided with a more consistent approach to care. Staff training should be provided to increase staff’s skills, knowledge and understanding to ensure that service users are protected. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 6 The improvements to the fabric of the home should continue to meet the programme set by the manager. 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. Charnwood DS0000018873.V362750.R05.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 DS0000018873.V362750.R05.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): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment is undertaken on all prospective service users to identify their needs and to ensure that those needs can be met. EVIDENCE: The home has produced a detailed service user guide which is issued to all prospective service users to enable them to have full details of the services and facilities offered by the home prior to their admission. Copies of these are held in the foyer of the home and are available on request. Improvements have been made to the pre-admission assessments made on service users. These are undertaken to ensure that the home has full information regarding the service users individual needs. A new document has been prepared for this purpose and allows the home to gather information Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 9 from the service user, their family and any health care professional involved in their care prior to admission. The assessments are undertaken by the manager or deputy manager and take place in the service user’s own home or in hospital as appropriate. The document is divided into sections, each requiring the assessor to record full information regarding the health, care and social needs. The pre-admission assessments for service users recently admitted to the home were inspected and were found to contain full information as required. Contracts are issued to all service users. These are issued by the Local Authority when funding is provided by them or by the home for service users who pay privately. The home does not offer intermediate care. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care files are informative and regularly reviewed and updated to provide staff with full information regarding service users care needs to ensure that those needs are met. EVIDENCE: Individual care plans are prepared for service users following their admission. This is to ensure that all staff are given full information regarding the care that they will need to give to the service users. There is great improvement in the information recorded in the plans. Risk assessments are in place together with information for staff to enable all risks to be reduced or removed where possible. All care plans are now reviewed on a regular basis and documentation regarding the changing needs of service users is held on their files, together Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 11 with information for staff. Regular audits are undertaken on files to ensure that they are well maintained and up to date. A selection of care files were inspected and each was found to contain full information as required. Daily records completed by the staff are informative and provide evidence of the actual care given. Records are held of visits to and by other healthcare professionals and information given by these professionals is detailed. Care plans are updated as necessary. Medication Administration Record sheets were inspected and found to be well maintained and up to date. Regular audits are undertaken on medications to ensure service users are protected. All medications are securely stored and the storage trolley was clean and organised. Medications are delivered directly to the home by the pharmacist but the records show that sporadic deliveries have the potential for service users running out of medications. It is only due to the efficiency of the staff and their immediate actions that this has not been allowed to happen. Comprehensive audits of medications are made to ensure that service users medications are provided and administered appropriately to ensure their protection. Discussion took place with the manager and deputy manager regarding the various methods of medication storage containers and the manager said that she would look into these with the dispensing pharmacist. Service users spoken to confirmed that their privacy and dignity is respected at all times. Shared bedrooms are provided with screens to protect individual service users privacy. Personal care is given in service users own bedroom or in the bathroom as appropriate. Charnwood DS0000018873.V362750.R05.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A high number of activities are provided for service users to provide them with a range of social opportunities and stimulation. EVIDENCE: The service users enjoy a high number of activities. The home employs an activities co-ordinator each Wednesday and alternate Fridays. Four service users enjoy going to a luncheon club each week and arrangements are being made for a fifth service user to accompany them. Staff are involved in activities and these include dominoes, video afternoons, drawing and painting, music, singing and more recently, a knitting club. Entertainers visit the home every three weeks to provide further social stimulation. Members of Clergy visit the home on a regular basis to provide services and arrangements can be made for service users to visit churches of their choosing in the local area. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 13 Visitors are welcome at the home at any time and service users may meet with their visitors in the privacy of their own bedroom or in one of the communal areas. Some service users are taken out by friends and relatives. The main meal of the day is served in the evening. A choice of cereals, porridge and toast is served for breakfast and a light lunch is served. A choice of meals is offered and the staff were able to demonstrate that they were aware of each service users preferences. Snacks and drinks are served between meals and are available at all times on request. Meals are generally taken in the dining room but can be served in service users own bedrooms on request. Dining tables are attractively laid and the meal served on the day of the visit looked and smelled appetising. Staff assist service users in a dignified manner where required and it was evident that mealtimes are not rushed. The kitchen is clean although care should be taken with stock rotation to ensure that dry and tinned goods do not become outdated. Food stocks were good and a supply of fresh fruit and vegetables were available. Charnwood DS0000018873.V362750.R05.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 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 has a good complaints procedure to ensure that service users are protected. EVIDENCE: The home has a comprehensive complaints procedure which is detailed in the Service User Guide and is also displayed in the foyer of the home. No complaints have been received by the home since the last inspection. The home has a policy in relation to the protection of vulnerable adults and a procedure to be followed in the event of abuse being suspected. In house training is given on abuse to ensure that all staff are aware of the action to be taken. The manager has recently attended a training course on Abuse and will give full information on the outcome to the staff. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 15 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, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and fresh and the programme of redecoration and refurbishment has commenced to further improve the home. EVIDENCE: A programme of redecoration and improvements within the home has commenced. The large front bedroom on the ground floor was being redecorated at the time of the visit and new carpet was due to be laid. The programme for the next twelve months includes one identified bedroom followed by the dining room, the lounge and then other bedrooms. A tour of the home showed that some of the carpets had become worn and stained and require replacement. These had been identified as requiring replacement and were detailed on the improvement programme. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 16 The extensive garden at the rear of the home is attractive and safe and is very well maintained. A large lawn is bordered by trees, flowers and shrubs and is extremely pleasant. Seating is provided for service users who can use the garden at any time. The entrance to the garden is available from the lower ground floor which can be accessed via the passenger lift. Service users bedrooms are bright and spacious and have been personalised with pictures, photographs and items of memorabilia to provide a warm and homely environment. Two of the bedrooms are currently used by staff and so were not inspected. A tour of the premises showed that there is currently some disorganisation within the home due to the commencement of redecoration programme, however, every effort is being made to ensure that this does not have a detrimental affect on service users and that their safety is assured. The home was found to be clean and fresh throughout. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 17 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. An increased level of training is necessary to ensure that staff knowledge and understanding is increased so as to meet service users needs. EVIDENCE: No new staff have been recruited by the home since the last inspection. The home has produced a comprehensive recruitment procedure which is in place in preparation for new staff. The positions of bank staff are currently being advertised to provide flexible working for staff and consistency of care for service users. All prospective staff will be required to attend for interview following completion of an application form. Criminal Record Bureau and Protection of Vulnerable Adults registers will be checked to ensure that service users are protected. An induction training programme has been prepared and will be used for the training of new staff. At present, vacant positions are being covered by agency staff. Regular staff are used to provide a consistent approach to care for the service users. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 18 Staff files have improved since the last inspection. Staff confirmed that in house training has been given but the records relating to this are sparse. No external training has been undertaken due to the shortfall in staff numbers. It is essential that all staff who handle food complete a basic food hygiene training course to ensure that service users are protected. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear records are now held of safety certificates for equipment used and for the fabric of the building to ensure the safety of service users, visitors and staff. EVIDENCE: The Registered Manager is also the owner of the home and lives on the premises. She is available to service users, staff and visitors at all times. The manager is experienced in care provision and in managing care services for elderly people. The home also employs an experienced deputy manager. An administration manager is responsible for organising the systems and Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 20 processes within the home and has prepared an internet web site which gives full information regarding the facilities and services offered by the home. Service users spoken to said that they were very happy with the care they received and that the staff were kind and caring. One service user confirmed that he is free to go out and that he enjoyed shopping in Birkenhead. Another service user said that he liked to spend time in his room and that this was respected by the staff who did everything they could to meet his needs. One visitor spoke highly of the home and said that his relative was well cared for. Service users confirmed that the food was good and that they knew who to speak to if they had any concerns. All agreed that they had no concerns. The home does not manage the service users money as this is attended to by relatives or advocates. Supervision is now given to staff and records of this are held on their files. Staff confirmed that the manager worked with them to ensure that the care given to service users was high. Regular tests are made on the fire detection equipment and are appropriately recorded. Safety certificates were inspected and were found to be up to date and well maintained. The organisation of the record keeping has continued to improve and all records were available for inspection. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 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 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 22 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. 2. Refer to Standard OP27 OP30 Good Practice Recommendations The programme of staff recruitment should continue to ensure that the home employs sufficient staff to meet the needs of service users. Staff training needs should be identified and appropriate training provided to ensure that staff have the knowledge and skills to meet the needs of service users. Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 Tustin Court Port Way Preston, PR2 2YQ 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 Charnwood DS0000018873.V362750.R05.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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