Inspection on 19/10/05 for Charnwood

This inspection was carried out on 19th October 2005.

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 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 16/05/07

Charnwood 22/05/06

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 Peter Cresswell Unannounced Inspection 19th October 2005 9:00 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 DS0000018873.V260251.R01.S.doc Version 5.0 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.V260251.R01.S.doc Version 5.0 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.V260251.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person over the age of 65 with mental disorder may be accommodated 3rd May 2005 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 five were in single rooms. One of the rooms is used as a staff sleep-in room and is therefore not available for residents. 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.V260251.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and a second inspector, Andrea Morris, accompanied the lead inspector. The inspectors spoke to a number of residents, the Registered Manager (who is also one of the owners) and the deputy manager. They examined records concerning staff recruitment, supervision, training, fire safety, care plans and catering. The inspectors toured the building, including the kitchen and food stores, and also inspected the home’s medication records and procedures. What the service does well: 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. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 6 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.V260251.R01.S.doc Version 5.0 Page 7 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. Standard 6 is not applicable. Residents are assessed before moving into the home and are encouraged to visit the home before making a final decision, helping them to decide if the home is the right one for them. EVIDENCE: Copies of the assessments made before admission are normally kept on residents’ files, but no written assessment had been prepared for the most recent admission. The Registered Manager said that this was because the resident had decided to stay as soon as he had visited the home. Prospective residents and their families are encouraged to visit Charnwood before deciding if they want to live there. The home does not provide intermediate care so Standard 6 does not apply. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 8 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, 10. Care plans and daily reports are good and help to ensure that residents receive care that is appropriate to their needs. Medication is stored and administered properly, protecting the health and welfare of the residents. Personal support is provided in such a way as to preserve residents’ dignity. EVIDENCE: There are care plans on residents’ files setting out their needs and how they are to be met by the staff at Charnwood. The manager reviews the care plans quarterly and they are amended and updated as necessary. Copies of the care plans are also kept in the Daily Reports file so that staff’s write-ups are informed by the plan. Medical appointments are recorded separately on the file. Medication is well organised and the home uses a NOMAD system of preloaded plastic cassettes. The Registered Manager and the deputy have introduced a system for recording the receipt and return of medicines but this needs to be extended to those prescribed medicines which are not in NOMAD cassettes. The home does not use non-prescribed homely remedies and had no controlled drugs at the time of this inspection, nor any drugs that require refrigeration. In the event of medication requiring refrigeration being prescribed the Registered Person will need to buy a small fridge which can either be locked or kept in a locked room. Residents receive personal care in Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 9 the privacy of their own rooms and screens are used in shared rooms. Staff who administer medication have received appropriate training. Residents are registered with General Practitioners and all visits by health professionals are clearly recorded. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 10 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, 15. The home provides some activities which enhance the lives of its residents and is planning to extend this, which would further improve residents’ well-being. The menu is well balanced and served at reasonable times, meeting the needs and tastes of the residents. EVIDENCE: Several residents told the inspectors that they have regular contact with their families and the home encourages visits by friends and relatives at any time. The Registered Manager said that the home provides activities such as jigsaws, quizzes and knitting each afternoon and during the inspection some residents were playing dominoes or knitting. Others were reading, chatting or watching the television. Some local trips were organised in the summer, using transport from Wirral Community Transport. Some residents commented that they did not feel there were many activities but others said that they do sometimes go out with staff. A record is kept of activities though it does not specify who took part in them. An entertainer visits the home once a week and the Registered Manager said that she was considering the appointment of a part time activities organiser. This would be a great potential benefit to the residents as such a member of staff would be able to focus solely on activities, without the competing demands of other work. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 11 Lunch is usually a light meal and the meal served on the day of the inspection was varied and well presented. The main meal is served in the late afternoon/evening, which suits the residents. Residents generally enjoy the meals and find them to their taste. The day’s meals are displayed on a notice board but on the day of the inspection the information provided was out of date. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Charnwood has appropriate policies in respect of complaints. EVIDENCE: The Registered Manager said that she has not received any complaints in the last year. Concerns raised by residents or their families are dealt with informally. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26. The home is clean, well maintained, and free from offensive odours, providing a comfortable environment for its residents. Residents have well-furnished, comfortable rooms though many of them are shared. EVIDENCE: Charnwood is clean, spacious, well maintained and homely in appearance. The home smelt fresh on this unannounced inspection and there were no offensive odours in any area. Work on improving the décor of the laundry has made no further progress. Some minor maintenance is needed in other areas: the vinyl floor covering in the ensuite to room 9 has lifted and must be refitted or replaced; a longstanding leak in the roof has re-emerged and damaged the décor to rooms 9 and 10 (particularly bad in Room 9); the vinyl flooring in the bathroom near to room 9 is lifting from the floor and the side panel to the bath has been damaged; the panel in the bathroom near to room 7 also has a damaged side panel. The ground floor toilet was in a generally poor state; the taps had been removed following damage caused by a resident, the toilet seat had also been removed following damage, the wallpaper was in a poor state and the lock was not working effectively. The manager said that this matter Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 14 was already in hand. The Registered Manager said that minor repairs have been delayed as the normal maintenance worker was not well. Several toilets did not have toilet rolls though the deputy manager said that she had told a care assistant to replenish them. Bedrooms are spacious and homely, and it is clear that in several rooms the residents have bought in items of their own furniture. Four bedrooms are shared at the moment and several residents said that ideally they would prefer a single room. Such residents should be given the opportunity of a single room as and when the opportunity arises. The garden is especially large and is very well maintained; it is well used in the summer months though access is not especially straightforward. The front porch needs to be redecorated as it gives a misleading and negative first impression of Charnwood and does not reflect the well-maintained interior. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 15 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): 27, 28, 29, 30. The home does not have enough domestic staff and care staff are not yet appropriately qualified. This reduces the time staff have available to spend with residents. The home’s current recruitment procedures are inadequate and potentially leave residents at risk. EVIDENCE: The Registered Manager has appointed one new part time care assistant since the last inspection but Charnwood continues to rely on a very small group of long serving and hardworking staff. The manager also appointed a cleaner who proved to be unsuitable and only stayed for a few days. The only designated domestic hours are worked by a member of the family and most domestic tasks are therefore carried out by care staff which inevitably limits the time spent on activities, trips out and one to one contact. The Registered Person has not obtained a CRB or POVA clearance for the new member of staff. This is a breach of the Care Homes Regulations 2001 and is entirely unacceptable. Staff must not start work without POVA (Protection of Vulnerable Adults) clearance. One of the owners (the manager’s husband) is the chef. The Registered Manager arranges some training and staff have done recent training medication. No staff at Charnwood yet have NVQs but two staff are now studying for NVQ2 and the Registered Manager and her deputy continue working towards NVQ4. Inevitably the home will fail to meet the standard of 50 of care staff with NVQ2 by the end of the year but it is commendable that NVQ training has started. The Registered Person may wish to check with the government agency NARIC if any of the qualifications of her overseas staff are equivalent to care sector NVQs. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 16 Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 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, 38. The manager is highly experienced but the home does not have adequate systems for staff supervision or quality assurance, though some supervision has started. Unless these systems are introduced the home may find it difficult to maintain the good level of service provided to residents. Fire safety measures need to be kept in place to ensure residents’ safety. EVIDENCE: The Registered Manager is very experienced and is studying for the Registered Manager’s Award. Residents’ questionnaires were introduced some months ago and the inspector discussed with the manager how the use of questionnaires could be expanded to form the beginnings of a quality assurance process. The Registered Manager said that she was planning to introduce a formal quality assurance mechanism via an external consultant though there was no timescale for this. Residents and their families handle residents’ finances. Templates for staff supervision are available in the home Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 18 and the manager has begun to carry out some supervision though this does not yet amount to a formal supervision programme. Fire safety records were mainly up to date but last fire drill had not been recorded. If drills and training are not recorded there is of course no evidence that they have taken place. During the inspection a number of fire doors were propped open. If a fire door is held open (other than by an approved hold-open device) it cannot carry out its function of preventing the spread of smoke and fire. If staff and the Registered Person wish to keep doors open then they must be fitted with a mechanism which closes them automatically in the event of an alarm being sounded. Accidents are fully recorded but the Accident Book does not conform to the requirements of the Data Protection Act. Suitable books are readily available and allow for each accident report to be detached and filed so that every report can be viewed in isolation. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 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 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 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 OP27 Regulation 18 Requirement Timescale for action 01/01/06 2. OP29 19 2. OP33 24 3. OP19 23(2) The Registered Person must employ additional domestic staff to meet the staffing standards set by the previous registering authority. (Originally required by December 2004.) The Registered Person shall not 19/10/05 employ a person to work at the care home unless they are fit to do so and have POVA clearance. The Registered Person must 01/02/06 make arrangements to review at appropriate intervals the quality of care provided in the home by introducing a quality assurance system. (Originally required by December 2004). The Registered Person must 01/02/06 ensure that the home is in a good state of repair and in order to do so must: repair or replace the vinyl in the ensuite to room 9; repair the water-damaged décor in rooms 9 and 10; replace or repair the vinyl flooring and side panel in the bathroom near to room 9; repair or replace the side panel in the bathroom near to room 7; repair the seat, taps, DS0000018873.V260251.R01.S.doc Version 5.0 Charnwood Page 21 4. OP38 13(4) lock and décor in the ground floor toilet. The Registered Person must 19/10/05 ensure that all risks to the health and safety of residents are eliminated and in order to do so must: ensure that fire doors are kept closed unless held open by an approved hold-open device; ensure that fire safety training is recorded. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP19 OP23 OP27 OP36 OP38 Good Practice Recommendations The home’s appearance would be enhanced by the redecoration of the front porch area. Residents sharing a bedroom should be given the opportunity of moving into a single room when the opportunity arises. 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. The Registered Person should obtain an Accident Book which conforms to the requirements of the Data Protection Act. Charnwood DS0000018873.V260251.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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