Inspection on 03/05/05 for Charnwood

This inspection was carried out on 3rd May 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 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 10/07/08

Charnwood 06/12/07

Charnwood 16/05/07

Charnwood 22/05/06

Charnwood 19/10/05

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 9.00am 3 May 2005 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 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 F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Charnwood Address 68 Bidston Road, Oxton, birkenhead, Wirral, CH43 6UW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 652 1984 Mr David Ashcroft, Mrs Sheila Margaret Ashcroft Mrs Sheila Ashcroft PC Care Home Only 19 Category(ies) of OP - Old Age - 19 registration, with number of places Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One named person over the age of 65 with mental disorder may be accommodated Date of last inspection 20 September 2004 Brief Description of the Service: Charnwood is a 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 seven shared and five single bedrooms. On the day of this inspection there were 14 residents in the home. One of the single 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 F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was not announced. During the inspection the inspector toured the home, spoke to the manager and staff, inspected records - including care plans - and spoke to a number of residents, both in the lounge and in some individual rooms. What the service does well: What has improved since the last inspection? What they could do better: The home does not employ sufficient domestic staff so domestic tasks such as cleaning have to be carried out largely by care staff. The manager has yet to Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 6 finalise the introduction of staff supervision and quality assurance programmes. Although some training is provided the Registered Person needs to ensure that enough care staff have NVQ training. 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 F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 4, 5 and 6 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 kept on residents’ files, as are contracts. 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 F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, and10. The systems for the administration of medicines are acceptable, though a robust record is required to protect the residents regarding their prescribed medication. Personal support is provided in such a way as to preserve residents’ dignity. EVIDENCE: Residents have care plans on their files which set out their needs and how they are to be met by the home. The manager reviews the plans but it was not clear that the care plans are amended as a result of the reviews. Copies of the care plans are also kept in the Daily Reports file so that staff’s write-ups are informed by the plan. As a result the daily reports are often detailed and informative. Medical appointments are recorded separately on the file. Medication is well organised and the home uses a NOMAD system of preloaded cassettes. The system for recording the receipt and return of medicines was not clear and as a result it was difficult to check the quantities of some prescribed tablets which were not in the NOMAD cassettes. These are usually medicines which are to be taken ‘as required’. Residents receive personal care in the privacy of their own rooms and screens are used in shared rooms. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, and 15 The meals in Charnwood are good, meeting the dietary needs of the residents, and offer a choice if requested. Some activities are organised but residents would welcome more activities. EVIDENCE: Many residents told the inspector that they have regular contact with their families and the home encourages visits by friends and relatives at any time. The manager said that the home provides activities such as jigsaws, quizzes and knitting each afternoon but these are not recorded in any detail. Some trips out are planned for the summer, using transport from a local community organisation. Several residents commented that they did not feel there were many activities but others said that they sometimes go out with staff. The manager said that she was considering the appointment of a part time activities organiser. 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. Residents enjoy the meals and find them to their taste. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16, 18 Charnwood has appropriate policies in respect of complaints and adult abuse. EVIDENCE: The home has a complaints book but the manager said that she has not received any complaints in the last year. Concerns raised by residents or their families are dealt with informally. The home has an appropriate adult abuse policy. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 20, 21, 22, 23, 24, 25, and 26 The home is clean, well maintained, and free from offensive odours. EVIDENCE: Charnwood is clean, spacious and well maintained. The Registered Person has carried out an intensive programme of repairs and minor improvements in recent months. Radiator guards have now been fitted in all bedrooms. Work has begun on improving the laundry but as an interim measure it has been painted and cleaned up. Some minor work is needed: the carpet in room 9 is stained and must be cleaned or replaced; the vinyl in the ensuite has lifted from the floor and must be refitted or replaced; the support frame in the nearby toilet is rusted and must be repainted or replaced; the enamel in the bath near room 3 is badly chipped and must be repaired or replaced. Bedrooms are spacious and homely, and it is clear that in several rooms the residents have bought in items of their own furniture. The garden is especially large and is very well maintained; it is well used in the summer months. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 13 Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 29, and 30 The home does not have enough domestic staff and care staff are not appropriately qualified. This reduces the time staff have available to spend with residents. EVIDENCE: The Registered Manager has appointed some new staff since the last inspection but none of them stayed for more than a few days. As a result the home relies on a very small group of long serving and hardworking staff. The only designated domestic hours are worked by a member of the family. Most domestic tasks are therefore carried out by care staff and this limits the time spent on activities, trips out and one to one contact. One of the owners (the manager’s husband)is the chef. The Registered Manager arranges some training and staff have done recent training on Moving and Handling, First Aid and medication. However, there are still no staff with NVQs. Two staff are due to begin NVQ training shortly and the deputy manager has very recently started the Registered Manager’s award. Inevitably the home will fail to meet the standard of 50 of care staff with NVQ2 by the end of the year. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, 37 and 38. Although the manager is highly experienced the home does not have extensive systems for staff supervision or quality assurance. This will make it difficult to maintain the level of service provided to residents. EVIDENCE: The Registered Manager is very experienced and has recently begun a course of study for the Registered Manager’s Award. Some residents’ questionnaires have been introduced but these have not yet been built into a quality assurance process. The Registered Manager does not handle any residents’ money and this is all done by the residents themselves or their families. Templates for staff supervision are available in the home but no system of formal staff supervision is yet in place, though the Registered Manager said that it was about to start. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 16 One resident had bedrails fitted for her safety but no risk assessment had been completed and the advice of the District Nurse had not been sought. Bedrails can be a valuable aid to residents’ safety but they must only be used in line with the latest advice from the Medical Devices Agency and with the support of local health professionals. During the inspection staff were seen to use an armchair to block access to the stairs. The chair was removed at the request of the inspector but this type of restraint is entirely unacceptable. The Registered Manager said that she had been unaware of such a practice. The home has a wide range of policies and a policy on Moving and Handling has been introduced. The smoking policy did not make sense and was amended during the inspection. There were no photographs of residents on several of the files which the inspector examined. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 2 2 2 Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 18 Are there any outstanding requirements from the last inspection? 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 27 Regulation 18 Requirement 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 must 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 introduce a system to accurately record the receipt and disposal of prescribed medication. The Registered Person must ensure that the home is in a good state of repair and in order to do so must: clean or replace the carpet in room 9; repair or replace the vinyl in the ensuite; repair or replace the support frame in the nearby toilet; repair or replace the enamel in the bath near room 3. The Registerd Person must maintain the records as set out in Schedule 3 of the regulations, including a photograph of each Timescale for action 1 July 2005 2. 33 24 1 July 2005 3. 9 13(2) 1 July 2005 4. 19 23(2) 1 July 2005 5. 37 17 1 July 2005 Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 19 resident. 6. 38 13(4) The Registered Person must 1 June ensure that all risks to the health 2005 and safety of residents are eliminated and in order to do so must: arrange for full assessments and risk assessments if bed rails are fitted; ensure that staff do not block access to areas of the home unless authorised to do so. 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. Refer to Standard 27 36 12 Good Practice Recommendations The Registered Person should begin a programme of NVQ training for care staff with a view to achieving 50 of staff with NVQ2 by 2005 Staff should receive regular, formal supervision, of which a record is kept. It is recommended that the home maintain a record of the activities arranged for and which individual residents took part. Charnwood F52 F02 S18873 Charnwood V225602 030505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Liverpool Office 3rd Floor, 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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