Inspection on 16/05/07 for Charnwood

This inspection was carried out on 16th May 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

Charnwood 07/07/10

Charnwood 22/02/10

Charnwood 01/12/09

Charnwood 17/08/09

Charnwood 08/04/09

Charnwood 10/07/08

Charnwood 06/12/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood 68 Bidston Road Oxton Birkenhead Wirral CH43 6UW Lead Inspector Inger Moynihan Unannounced Inspection 08:45 16 and 18th May 2007 th 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.V331859.R02.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.V331859.R02.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) 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.V331859.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person over the age of 65 with mental disorder may be accommodated 22nd May 2006 Date of last inspection 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. On the day of this inspection there were 13 residents in the home and six were in single rooms. One of the rooms is used as a staff sleep-in room and is 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. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about Charnwood was obtained through a pre-inspection questionnaire and examination of the homes documentation. Discussion took place with residents, the deputy manager and members of the staff team. A tour of the building also took place. Prior to the inspection CSCI questionnaires were sent to a number of residents, their relatives and health care professionals who visit the home. Information from these questionnaires is included in the report and contributes to the basis of any judgements made. This inspection was carried out with the deputy manager. Fees - £334.86p per week What the service does well: A complaint procedure is in place to ensure residents know who to contact if they have any concerns to raise. Most parts of the home are well maintained and provide a pleasant environment in which to live. Most of the residents said the staff are always polite and friendly. They confirmed they receive their medication on time. One resident said the staff are very nice and always look after me. A number of residents commented on the kind and caring nature of the registered manager. There has been little change to the staff team since the last inspection. This is a positive aspect of the home and ensures continuity of care. Four relatives questionnaires returned to the CSCI indicated the service always meets the needs of their relatives and they are always kept informed of important issues affective their care. Three questionnaires indicated the staff always have the skills and experience to look after the residents properly. One questionnaire praised the manager and deputy manager in this instance. Three health care professional questionnaires were returned to the CSCI. All of the questionnaires indicated the service always respect residents privacy and dignity. When asked what the service does well?, one questionnaire recorded (the service) looks after its residents, the other questionnaire indicated the service delivers a high standard of care for each individual .... Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Charnwood DS0000018873.V331859.R02.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.V331859.R02.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 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no clear or consistent assessment system or risk management strategy in place to provide staff with the information they need on how to look after the residents and keep them safe from harm. EVIDENCE: Documentation is in place to demonstrate that residents care needs are assessed, however, the documentation used for this purpose differed from one person to another. In one instance a full Social Services assessment was in place, although the registered manager had not carried out her own assessment, and in another instance a more basic assessment document was used. Residents family are involved in the assessment process to make sure their move into the home is as comfortable as possible. The residents spoken to during the visit said their care needs were met. Intermediate care is not provided at the home. Charnwood DS0000018873.V331859.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no clear or consistent care planning system or risk management strategy in place to adequately provide the staff team with the information they need on how to satisfactorily meet residents needs and keep them safe from harm. EVIDENCE: A documented plan of the care provided to each resident, is available but little progress has been made to ensure that all aspects of health, personal and social care needs are regularly identified, reviewed and updated. Care plans that are in place are poorly developed, out of date and do not reflect the person. Residents have access to a range of health care professionals such as a chiropodist, dentist and optician. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 10 Most of the residents said the staff are always polite and friendly. They confirmed they receive their medication on time. One resident said the staff are very nice and always look after me. A number of residents commented on the kind and caring nature of the registered manager. Three questionnaires indicated the staff always have the skills and experience to look after the residents properly. One questionnaire praised the manager and deputy manager in this instance. Comments made in the questionnaires included, I am more than satisfied with Charnwood care home. Another recorded the service affords appropriate care. Residents are clean and well dressed, medical needs are met and health menus are provided. Three health care professional questionnaires were returned to the CSCI. One questionnaire indicated the service usually seeks advice and acts upon it to manage and improve intervals health care needs, the other questionnaires indicated this always happens. Two questionnaires indicated staff always have the skills and experience to support residents social and health care needs with one questionnaire indicating this is usually the case. All of the questionnaires indicated the service always respect residents privacy and dignity. Two questionnaires indicated the staff always supports individuals to live the life they choose, the other questionnaire indicated this usually happens. When asked what the service does well?, one questionnaire indicated (the service) looks after its residents, the other questionnaire indicated the service delivers a high standard of care for each individual.... Appropriate storage facilities are in place for medication and only trained staff are allowed to give medication. All of the staff have completed some degree of training. None of the residents take responsibility for the administration of their own medication. Records of compliance with medication administration, safekeeping and disposal are not up to date and fully comprehensive. There is no quality assurance in place in respect of the medication. Charnwood DS0000018873.V331859.R02.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. 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. The homes routines are flexible which means residents can exercise choice in their lives. The range of social activities need to be improved to ensure a more stimulating environment is provided. EVIDENCE: A range of social activities are provided and an activity organiser visits the for two hours twice a week. There is a range of board games available and residents can join in with singing when a pianist visits. A number of the residents said they enjoyed the activities provided although some said they would like more things to do. The residents confirmed their family and friends can visit at any time, which means they can maintain personal relationships. This was confirmed in the three questionnaires returned to the CSCI from relatives. The pre inspection questionnaire indicated that a two-week menu is in place. The residents said they enjoyed the food and always had plenty to eat and drink. Lunch was observed during the visit, this was a quiet and relaxed time with staff communicating with residents in a polite and respectful way. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 12 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 poor. This judgement has been made using available evidence including a visit to this service. The lack of adult protection awareness does not ensure that the people living in the home are protected from abuse. EVIDENCE: Staff have not been provided with training on how to keep the residents safe from abuse and harm although during discussion some staff did demonstrate an understanding of this issue. Policies and procedures for safeguarding adults need to be robust and clear guidance about what staff should do if they receive an alert, needs to be in place. Most of residents reported the staff are very kind, one resident stated the staff are all very kind and friendly. The pre inspection questionnaire indicated that no complaints have been made to the home and that a complaint procedure is in place so that residents know their concerns will be dealt with correctly. All of the staff spoken to during the visit knew what action to take in the event of them receiving a complaint. Three of the relatives questionnaires indicated they knew how to make a complaint. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are maintained and provide residents with a comfortable environment to live in, however improvements in some areas need to be made to ensure the residents safety. EVIDENCE: The home is spacious, adequately furnished and homely in appearance. There is a lovely garden at the back of the home, which residents can use when the weather is good. All bedrooms are bright and spacious and residents had personalised their rooms with their own belongings, which gave a comfortable and homely environment. There is a programme of routine maintenance in place for the decoration of the premises, however work on improving the décor of the laundry room still requires attention. The front of the home is untidy with building rubble, sand and other items being stored there and the flooring and décor in some of the bathrooms requires attention. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. The poor recruitment practices and lack of staff training do not promote residents safety or a person centred approach to care. EVIDENCE: There are no separate domestic staff employed at the home, which means the care staff have to carry out these duties. The pre inspection questionnaire indicated that no training has been provided in the last 12 months although the registered manager is in the process of setting up future training. There is no comprehensive training plan and there are no records of staff training. Recruitment records were not always completed with the necessary checks being in place prior to staff starting work. Criminal Record Bureau (CRB) check’s had not been completed for some staff and two staff references had not always been taken up prior to employment. Staff are provided with an induction when first employed although no record of this induction training is kept. One of the newly appointed staff spoken to Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 15 during the visit confirmed they had completed an induction when first employed. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 16 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, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of systems in place to ensure the ongoing monitoring and improvement of the service, which ensures the health, safety and welfare of the residents needs to be improved. EVIDENCE: The registered manager who is also one of the owners has been running the home for many years and is knowledgeable on the care of the residents who use the service. There is no effective quality assurance system in place to ensure the standard of care in the home is improved together with systems that monitor practice and compliance with care plans, policies and procedures. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 17 The home does not manage residents money as their family carry this out. Staff reported they are supervised informally and feel well supported in their role. They confirmed a senior member of staff is always available for advice and support. There is no formal system of supervision in place for the purpose of enabling staff to develop in their role. The pre inspection questionnaire indicated that a range of policies and procedures are available for staff reference, though a number of them had not been reviewed or updated for a number of years. Checks have been carried out on various equipment around the home including the fire safety equipment. However on the day of the visit fire exits were blocked and the fire risk assessment had not been completed. There was a lack of clear health and safety information and staff had not had training in health and safety matters to enable them to work safely. Cleaning materials were seen left around the home, temperatures of hot water had not been recorded, risk assessments in relation to the use of bed rails had not been completed and the electrical wiring certificate was out of date. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 18 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 2 1 1 Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 19 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 OP3 Regulation 14 Requirement A detailed assessment of residents care needs must be carried out to ensure staff have enough information on how to provide person centred care. Risk assessments must be carried out to ensure staff can protect the residents from the risk of harm. An up to date written plan of care must be available, kept under review for each resident to ensure their health, personal and social care needs are met. Previous timescale has not been met. Up to date records of compliance with medication administration, safekeeping and disposal of medicines must be available to ensure residents are protected by the homes policies and procedures. Residents should be consulted about their social interests and about an programme of activity to ensure the lifestyle experienced in the home matches their expectations and DS0000018873.V331859.R02.S.doc Timescale for action 31/07/07 2 OP3 13 31/07/07 3. OP7 15 31/07/07 4 OP9 13 18/05/07 5. OP12 16 30/07/07 Charnwood Version 5.2 Page 20 6 OP18 13 7. OP19 23 8. OP27 18 9. OP27 18 10 OP30 18 11 OP29 19 12 OP33 24 preferences and satisfied their social, cultural and recreational needs. All staff must receive training on safeguarding adults and have up to date written information to ensure residents are protected from abuse and exploitation. The laundry room, the front of the home and bathrooms areas must be kept clear, clean, decorated and well maintained to ensure the residents live in a safe and well-maintained environment. A staff rota showing which staff are on duty at any time during the day and night and in what capacity must be made available to ensure residents needs are met the by the numbers and skill mix of staff. Previous timescale has not been met. Domestic staff should be employed to ensure the home is maintained in a clean and hygienic state. Previous timescale has not been met. All people employed in the home must receive training appropriate to the work they perform. Written records must be kept to show what induction and subsequent training staff have had to ensure they are competent to do their job. Previous timescale has not been met. All persons prior to working at the care home must have had a criminal records bureau (CRB) clearance check and 2 written references taken up to ensure that they are suitability qualified to work with vulnerable adults. Previous timescale has not been met. The registered persons are DS0000018873.V331859.R02.S.doc 30/07/07 31/07/07 18/05/07 18/05/07 31/07/07 18/05/07 31/07/07 Page 21 Charnwood Version 5.2 13 OP37 17 14 OP38 23 required to make arrangements to review at appropriate intervals the quality of care provided in the home by introducing a quality assurance system. Previous timescale has not been met. A range of up-to-date policies 31/08/07 and procedures must be available for staff reference at all times. This will ensure staff are clear on their responsibilities and have the necessary guidance on how to care for the service users in line with good practice and ensure they are safe from the risk of harm. Fire exits must be kept clear at 18/05/07 all times and that fire safety risk assessments completed to ensure residents safety and welfare at all times. 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. 4. 5. 6. Refer to Standard OP27 OP36 OP23 OP2 OP9 Good Practice Recommendations The Registered Person should continue the programme of NVQ training for care staff with a view to achieving 50 of staff with NVQ2. Staff should receive regular, formal supervision, of which a record is kept. Residents sharing a bedroom should be given the opportunity of moving into a single room when the opportunity arises. Service users who are funded by a local authority should be provided with a statement of terms and conditions. It is advisable to mark the date of opening on the container of medications with a limited shelf life following opening (such as ear drops). The Registered Person should investigate other means of safely storing DS0000018873.V331859.R02.S.doc Version 5.2 Page 22 Charnwood medication requiring refrigeration. Charnwood DS0000018873.V331859.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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.V331859.R02.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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