Inspection on 01/06/06 for Charnwood Care Home

This inspection was carried out on 1st June 2006.

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 Care Home 23/06/08

Charnwood Care Home 28/06/07

Charnwood Care Home 04/05/05

Charnwood Care Home 01/09/04

Charnwood Care Home 20/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood Care Home 29 Station Road Carlton Nottingham NG4 3AX Lead Inspector Karmon Hawley Unannounced Inspection 10:00 1st June 2006 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 Care Home DS0000026425.V288107.R01.S.doc Version 5.1 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 Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Charnwood Care Home Address 29 Station Road Carlton Nottingham NG4 3AX 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) 01159404441 01159875008 Ashbourne Health Ltd Mrs Mary Ledger Care Home 88 Category(ies) of Old age, not falling within any other category registration, with number (81), Physical disability (4), Terminally ill (3) of places Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Physically Disabled clients to be aged 50 years and above. Palliative Care clients to include one aged 45 years or above. One Service User within category PD may be aged 49 years or older Service users shall be within categories OP, PD or TI Date of last inspection 27/10/06 Brief Description of the Service: Charnwood is a registered care home providing both nursing and personal care. The home is located in an inner city area of Nottingham, close to the local shops, general practitioners surgery and other amenities. The accommodation is a purpose built building, with two units offering a total of 88 beds, comprising of 60 single rooms nine of which are ensuite and 14 double rooms one of which is ensuite. All bedrooms are fitted with an alarm call system and are suitably furnished, however service users are encouraged to personalise their own rooms. There is one large lounge within each unit, incorporating a designated dining area. There is a pleasant garden access leading from patio doors. The current weekly fees are as follows: residential care £319 plus £10 top up for a shared room and £20 top up for a single room, nursing care £343 plus £10 top up for double room and £20 top up for a single room. Private residential care starts from £375 and private nursing is £437. This information is made available on the point of enquiry. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over course of four and a half hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of six randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users and tow relatives were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager assisted in the inspection process and three members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: What has improved since the last inspection? Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 6 The lounge in the court unit has been refurbished offering a comfortable and welcoming environment for service users. Service users reviews have continued to develop thus enhancing the continuity of care. Appropriate risk assessments are now in place ensuring service users are protected. Medication procedures have improved ensuring service users are protected. The issue of odour in the smoking room has been addressed and this is improved thus ensuring a more comfortable environment for service users. Relevant policies and procedures remain in place in the kitchen to ensure service users are protected. All staff have photographic identification in place, thus enhancing service user protection. 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 Care Home DS0000026425.V288107.R01.S.doc Version 5.1 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 Care Home DS0000026425.V288107.R01.S.doc Version 5.1 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 the following standard(s): 3 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the home. Service users may be assured their needs will be assessed and met prior to moving into the home. EVIDENCE: The home manager visits prospective service users in the community and carries out pre admission assessments prior to them moving into the home. Service users may also visit the home and assessments may be carried out on the premises. The assessment covers the requirement of the standard. New documentation is being introduced in line with Southern Cross policies; this assessment was noted to be in depth. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in an individual plan of care. Service health care needs are fully met. Service users are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their rights to privacy is upheld. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 10 EVIDENCE: Improved care plan packages are in the process of being introduced in line with Southern Cross methodology. A number have been completed and this process is due to be finalised by July 22006. Service users undergo various assessments in relation to the activities of daily living, pressure area care, manual handling, falls, nutrition and continence, information gained underpins the plan of care. Plans of care in place were in depth, personalised and reflected choices and preferences whilst recognising highlighted needs. Appropriate risk assessments were in place for highlighted risks. Daily progress notes were maintained and contained information with regards to significant events and service users care and condition. There was evidence of reviews taking place, however a number were not service user focussed to reflect service users care and condition. The manager stated that due to the new documentation introduced, these would continue to improve and were now part of the monthly auditing procedure. Service users spoken with stated that their needs were met and they were happy with care received. Both relatives spoken with stated that care offered was at a good standard. Staff spoken with were able to discuss service users needs and the core values and principles and stated that they felt a good standard of care was delivered. There was evidence available within plans of care to demonstrate that service users health care needs are met. The manager stated that good relations are maintained with the multidisciplinary team and services are accessed, as required and relevant aids are available. Appropriate policies and procedures with regards to dealing with medicines were in place. Service users medication checked with the prescription was correct. Staff are trained in the safe administration of medicines. Two members of staff signed handwritten entries. An appropriate policy with regards to the disposal of medicines was in place. Staff are instructed in maintaining service users privacy and dignity during the induction process and whilst undergoing resident welfare training. Service users may receive visitors in private should they wish. Service users spoken with stated that staff were kind and respectful and privacy was maintained. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users find the lifestyle experienced in the home matches their expectations and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing diet in pleasing surroundings. EVIDENCE: Within case notes examined there was evidence of social and recreational assessments taking place to highlight service users needs, preferences, likes and dislikes. Personal profiles were also available within all but one care plan observed ensuring service users history and life experiences were acknowledged. There are two activities coordinators employed and notices of arranged events were displayed along with an activities newsletter. A variety of activities take place including theme nights and a summer fayre has been Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 12 arranged based upon a football theme. Service users spoken with substantiated that activities were available and they enjoyed joining in. Two service users discussed the recent Parisian night and the trips taken outside of the home. An open visiting policy is employed and relatives are welcomed into the home, two relative spoken with felt they could visit at any time, were made welcome. Visitor may be received in private and there are areas available around both units to facilitate this, service users may also use their own rooms should they desire. Although advocates are not in use at present Age Concern is used if required. To ensure equality and diversity is acknowledged and maintained within the home all staff are trained in the core values and principles. Service users are informed of the homes statement of purpose and services on offer. It was evidenced within service users plans of care that individual choices and preference are taken into consideration and service users substantiated that they are treated with respect and choices are offered and upheld. Service users are able to bring in personal possessions in order to make their room more homely; this was evidenced during the tour of the home. There are at present no service user who deals with their own finances, however should they be able this would be accommodated. Advocates have been used in the past and would be again if required. There are two kitchens, one in each building. Each provides service users with a wholesome and appealing diet, which offers choice consistent to individual needs. Service users substantiated that food was of a good standard and choice was offered. Both relatives spoken with stated food was of a good standard and choices were available. Three main meals are offered a day and a light supper if required, the access to the kitchen can be gained twenty four hours a day should a service user request food and drinks are also always available. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 13 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): 16,18 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users and relevant others can be assured their complaints will be listened to taken seriously and acted upon. Service users are protected form abuse. EVIDENCE: There have been five complaints received since the previous inspection, all were of a minor nature and had been dealt with appropriately and resolved. Staff spoken with were able to discuss how complaints would be dealt with if received. All service users and the two relatives spoken with spoke highly of the home and expressed no complaints. One service user stated that they were assured that if they did complain this would be listened to. Relevant policies and procedures are in place with regards to adult protection. 97 of staff have undertaken training in resident welfare and staff spoken with were able to discuss this to a good standard. All staff employed have satisfactory criminal record bureau checks in place with the exception of one who has undergone the protection of vulnerable adults check and is currently supervised by senior staff until criminal record clearance has been received. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 14 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): 19,26 The quality rating for this outcome area is adequate this judgement has been made using evidence available including a visit to the service. Service users live in a clean, pleasant and hygienic satisfactory maintained environment, however improvements in décor in several areas are recommended. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 15 EVIDENCE: A maintenance man and a gardener are employed and there was evidence available to demonstrate that regular maintenance is undertaken. The lounge in the court unit has been refurbished and new flooring laid, refurbishment is planned for the main lounge in the house unit in the near future. There were areas within both units that also now require attention, the corridors being scratched and décor looking ‘tired.’ The environmental health officer has undertaken a satisfactory visit since the previous inspection and a visit by the fire authority has been arranged. One service user spoken with stated they enjoyed sitting out in the beautiful garden. The home was clean, pleasant and hygienic on the day of the visit and there are sufficient staff employed to maintain this. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 16 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 quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. The number and skill mix of staff meets service users needs. Service users are in safe hands. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: The duty rotas were observed and demonstrated that sufficient staff are employed. Skill mix is taken into consideration when planning the duty rota. Service users spoken with stated that staff were available to meet their needs. One relative spoken with stated staff were always available should they be needed and they would assist in any way they can. Staff spoken with stated there were sufficient staff available to meet service users needs, however stated that an additional member would be beneficial on occasion. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 17 10 members of staff have attained the national vocational qualification level 2; five members of staff have attained level 3. 19 members of staff are working towards the national vocational qualification level 2. There was evidence available to demonstrate that new staff undergo an induction on commencing employment. The induction programme is at a recognised standard. Four staff files were examined and demonstrated that all relevant checks and documentation were available as required. The training programme in place ensures all staff undergo mandatory training and staff have individual training files in place that substantiated this. An in house trainer works at the home and offers training on a weekly basis. Staff training statistics are sent to head office on a monthly basis and demonstrated that staff training is at a high standard. One relative spoken with stated they had confidence in the staff team. Staff spoken with stated they felt supported in training needs and relevant courses were available to them. The manager stated that two registered nurses have undergone a five-day course in palliative care. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 18 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 quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. 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 her responsibilities fully. The home is run in the best interests of service users. Service users personal finances are safeguarded. The health safety and welfare of service users and staff are promoted and protected. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 19 EVIDENCE: The manager is a registered nurse and has completed the National Vocational Qualification (NVQ) level four management award. She is also a NVQ assessor thus facilitating others training. She remains up to date with mandatory training and by attending courses relevant to her nursing qualification and the service users that she cares for. She has thirteen years experience in this field and has held her current position for four years. She manages both units of the home and floats between them. Staff spoken with stated that the manager was approachable and supportive. Service users have completed quality assurance questionnaires; the manager is in the process of consolidation so an action plan may be devised to address any areas required. These were observed and in general positive comments had been received. Where a negative comment had been received there was evidence to demonstrate that the manager had discussed this with the service user concerned. Service user and relative meetings are held on a regular basis, there was evidence of this taking place and minutes of these meeting were available. Personal allowances of those service users case tracked were checked; these corresponded with account records, receipts, and reasons for transactions were available. The administrator deals with accounts and there was evidence that these are consolidated on a monthly basis. The home has a central bank account which is used to deposit excess money for service users, the manager stated that attempts had been made to open individual accounts however had been unsuccessful. Records of individual money within this account were available. With regards to health and safety all maintenance certificates and checks were observed and were satisfactory. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 20 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 X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15 Requirement Service user reviews are required to be service users focused to reflect care, condition and outcomes. This has been partly met, however requires further development. Timescale for action 01/09/06 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 OP19 OP18 Good Practice Recommendations To consider the redecoration of the main hallways to ensure they are well maintained. To implement a supervision policy with regards to staff employed who are waiting a satisfactory criminal record bureau check. Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Extracts may not be used or reproduced without the express permission of CSCI Charnwood Care Home DS0000026425.V288107.R01.S.doc Version 5.1 Page 23 - 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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