Inspection on 06/12/07 for Charnwood

This inspection was carried out on 6th December 2007.

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood 68 Bidston Road Oxton Birkenhead Wirral CH43 6UW Lead Inspector Jeanette Fielding Key Unannounced Inspection 6th December 2007 09:30 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.V353834.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charnwood DS0000018873.V353834.R01.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.V353834.R01.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 16th May 2007 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 12 residents in the home. 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.V353834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on one day over a period of eight hours. This was the key unannounced inspection and was carried out as part of the regulatory process. 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. Discussion took place with the registered manager, care staff and service users. The manager had completed a pre-inspection questionnaire to give further insight into the home. What the service does well: What has improved since the last inspection? What they could do better: The records, although improved, require additional work to ensure that they contain full information for all service users and staff. Staff training requires to be provided, although some has been arranged for the near future. Some carpets are in need of replacement due to their worn condition. Insufficient staff are employed to cover all care hours and a recruitment programme is underway. All staff are to be given training in the protection of vulnerable adults to ensure the protection of service users. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 6 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.V353834.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service User Guide and Statement of Purpose provide prospective service users with information regarding the facilities and services provided by the home to enable them to make an informed choice regarding their care provider. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide to give prospective service users sufficient information regarding the facilities and services provided by the home. Copies of these documents have been submitted to CSCI and are available from the home on request. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 9 A new pre-admission assessment has been prepared and is now in use for all prospective service users. This form allows for all the service users care and social needs to be identified to ensure that the home can meet those needs. Information is gathered from the service user, their family and any other person involved in their care. Sufficient information is gathered to enable the initial plan of care to be prepared. Individual preferences are also recorded at the pre-admission assessment to enable the staff at the home to provide for those preferences and thereby enhance the lives of the service users. The home does not offer intermediate care. Charnwood DS0000018873.V353834.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the care files to give staff greater information regarding the care needs of the service users to enable them to meet those needs. EVIDENCE: A new format for recording the plans of care has been introduced since the last inspection. Work is taking place to prepare these for all service users, but at present, only about half of the files have been reviewed and updated using the new format. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 11 Records are now in place to identify service users specific care needs and includes information for staff on how to meet those needs. Individual risks are identified and information is recorded on how to reduce or remove those risks to ensure the service users protection. Details are now recorded of visits made to and by GP’s and other healthcare professionals together with recommended changes to their care. The daily records completed by the staff give full details of the actual care given and provide evidence that the service users care needs are being met. It was evident that staff assist service users to maintain their standards of appearance as they did prior to entering the home. One female service user was observed to be wearing lipstick and others wore their jewellery. Service users spoken to said that the staff were kind and caring. One service user enjoys smoking and a designated area has been identified as a safe area for this. This does not impact on other service users who do not smoke. Medication records were found to be organised and up to date. Records are held of all medications entering and leaving the home and the audits undertaken by the deputy manager show that care is taken to ensure accuracy of recording at all times. The medications are securely stored and the storage area was clean and organised. Medication Administration Record sheets are signed by staff to indicate that the medications have been administered and these were found to be up to date and accurate. None of the service users administer their own medications and so all medications are administered by staff who have had training in this. Service users are accommodated in single or double bedrooms. Screens are provided in double rooms to provide greater privacy. Personal care is given in service users bedrooms or bathrooms as appropriate and staff were observed to speak with service users quietly and with dignity when referring to personal care. Charnwood DS0000018873.V353834.R01.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. Service users are free to choose their own lifestyle within the home and a range of choices and opportunities are offered. EVIDENCE: A range of social activities are provided for service users and a programme has been prepared. The weekly activity list is displayed for service users and they are free to choose whether or not they participate. An Occupational Therapist visits the home each week to provide further stimulation. Staff were observed to be playing dominoes with two service users. Both service users confirmed that a range of activities and games were available and that they participated on a regular basis. Planned activities include Bingo, Art, Topical Debates, Singing and Quizzes. Two service users attend a day centre twice each week and both enjoy these days out. Some service users go out on a regular basis and a shopping trip has been arranged to enable service users to purchase personal items and Christmas presents. Ministers and Church Elders visit the home each week and provide services for those service users to choose this. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 13 Relatives and friends are welcome to visit the home at any time and service users are free to meet with their visitors in the privacy of their own bedroom or in the lounge or dining room. Service users confirmed that they are free to choose their own lifestyle within the home. They are free to choose the time that they go to bed and rise and where they spend their day. The home is now producing a monthly newsletter for service users and relatives. It provides information about service users birthdays, events and a quiz. It is hoped that this will be available to relatives of former service users who still visit and support the home. Service users may choose a cooked breakfast if they wish but most enjoy cereal and toast. The main meal is served in the evening with a lighter meal at lunchtime. Snacks and drinks are offered between meals and are available at all times on request. The menu provided evidence that a varied and balanced diet is provided and that special diets can be provided on request or on the advice of the GP or dietician. Dining tables were attractively laid and lunch was observed to be a relaxed occasion with service users chatting freely amongst themselves. The kitchen was clean and organised and a good stock of fresh goods were seen. All foods were appropriately stored and the storage area was clean and organised. Charnwood DS0000018873.V353834.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. Training is required in the Protection of Vulnerable Adults to ensure that all service users are protected. EVIDENCE: The home has a complaints procedure which is detailed in the Statement of Purpose and 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. Staff were aware of the procedure to be followed in the event of a complaint being received. Only one of the staff has received training on the Protection of Vulnerable Adults (POVA). Training has been arranged with Wirral Borough Council for later in December. Three staff who had been given this training have recently left the home, two to have babies and one who has left the area. Staff spoken to during the inspection were aware that any incidents had to be reported but were not sure of the procedure to be followed. This will be resolved following the training when the full procedure will be explained. Charnwood DS0000018873.V353834.R01.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, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and fresh and provides service users with a homely environment but some carpets require replacement to further improve service users bedrooms. EVIDENCE: The home is spacious and homely in appearance. At the rear of the home is a large garden which is attractive and well maintained. Seating is provided and a gazebo in the summer months. Service users bedrooms are bright and spacious and have been personalised with pictures, photographs and items of memorabilia to provide a pleasant and homely environment. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 16 There is a programme of redecoration and refurbishment which continues. New carpets for the lounge, dining room and hallways are planned and quotes for these are currently being obtained. It is planned that the new carpets will be fitted within the next three months together with new curtains. Plans are also in place to replace armchairs in the lounges to further enhance the environment and to provide greater comfort for service users. Two of the bedrooms were being used by staff and were not inspected. All other areas of the home were inspected. Four of the bedrooms have carpets which have become worn and faded and will need to be replaced in the near future. The décor in one bedroom on the ground floor is now in need of redecoration as it is faded and damaged in parts. The bath panel on the bath opposite room 6 is damaged and requires replacement and the seal around the bath needs replacing. The laundry has been redecorated since the last inspection and is bright and clean. It was observed that incontinence pads are being stored in bathrooms. The damp air in these rooms damages the pads and makes them less effective. These should be stored within a dry environment. The home was found to be extremely clean and fresh throughout. Charnwood DS0000018873.V353834.R01.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. Training is planned to develop the staff team to ensure that they have the skills and experience to meet the needs of the service users. EVIDENCE: A programme of staff recruitment is currently taking place and positions are advertised in the local Job Centre and in the press. There is a shortage of staff at present and so additional hours are being worked by current staff at their request to cover the shortfalls. On occasions, agency staff are employed to cover hours where current staff are not available. No new staff have been employed since the last inspection and so it was not possible to inspect the current recruitment procedure. Work is taking place to improve the staff files but more information is required to be included. There is no evidence that staff have been given induction training but a new form has been prepared which details the training that will be given. A copy of the form to be used has been given to CSCI. The induction training should now follow the Skills for Care format to include induction and foundation training. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 18 The staff files do not include details of training. A range of training has been planned for the coming weeks which includes POVA, Food Hygiene, Health and Safety and Risk Assessments. Evidence of in-house training should also be included in the staff files together with evidence that competency has been evaluated. The manager and deputy manager are planning to undertake management training to NVQ level 4 but no date of commencement has yet been arranged. All staff employed at the home are experienced in providing care to elderly people and service users confirmed that the staff were kind and caring and met all their needs. One member of staff holds NVQ at level 2. A new procedure has been prepared for the recruitment of staff and this will be inspected at the next inspection when new staff have been appointed. Charnwood DS0000018873.V353834.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager is well supported by the staff team. More work is needed to improve the records within the home and thereby ensure that service users are protected. EVIDENCE: The Registered Manager is also the owner of the home and is available to service users, staff and visitors at all times. The home also has a deputy manager who is experienced in the care of elderly people. An Administration Manager has recently been appointed to produce necessary documentation and organise the systems and processes within the home. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 20 A new web site has been produced which provides prospective service users with additional information about the home and pictures. It is evident that the primary function of the home is to meet the care and social needs of the service users, however, additional training is required by the staff to provide evidence of skills and competence. The home does not manage the service users money as this is attended to by relatives or advocates. Staff confirmed that they are given informal supervision during the working day by the manager or deputy. Formal supervision arrangements are currently being organised. The majority of policies and procedures have not been reviewed or updated since 2002. The fire safety procedure has been updated to reflect changes in fire regulations. Safety certificates were in place for the electrical wiring, gas, the lift and the fire detection equipment. Tests have been made on the water for Legionnella and the hot water temperature is tested regularly to ensure that there is no risk to service users from scalding. The portable appliances have not yet been tested and confirmation has been seen to show that this will take place in January 2008. Charnwood DS0000018873.V353834.R01.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 22 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. 2. Standard OP7 OP18 Regulation 15(2) 13(6) Requirement The registered person must ensure that outstanding care files are reviewed and updated. The registered person must ensure that all staff receive training in the protection of vulnerable adults. The registered person must ensure that the damaged bath panel is replaced. The registered person must ensure that worn and faded carpets are replaced. The registered person must ensure that sufficient staff are employed at the home. The registered person must ensure that all staff are given training appropriate to the work they are to perform. Timescale for action 29/02/08 29/02/08 3. 4. 5. 6. OP19 OP19 OP27 OP30 23(2) 23(2) 18(1) 18(1) 31/01/08 30/06/08 29/02/08 29/12/08 Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 23 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 OP29 OP38 Good Practice Recommendations The new recruitment procedure and documentation should be used for all prospective staff. Evidence that portable appliances have been tested should be held in the home. Charnwood DS0000018873.V353834.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor 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.northwest@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.V353834.R01.S.doc Version 5.2 Page 25 - 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. 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