Inspection on 23/06/08 for Charnwood Care Home

This inspection was carried out on 23rd June 2008.

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 Care Home 28/06/07

Charnwood Care Home 01/06/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood Care Home 24 Station Road Carlton Nottingham NG4 3AX Lead Inspector Steve Keeling Unannounced Inspection 23rd June 2008 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 Care Home DS0000026425.V366860.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 Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood Care Home Address 24 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) 0115 940 4441 0115 987 5008 charnwoodcourt@shealthcare.co.uk The.willows@ashbourne.co.uk Exceler Healthcare Services Limited Care Home 88 Category(ies) of Old age, not falling within any other category registration, with number (83), Physical disability (5) of places Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Exceler Healthcare Services Limited may provide the following categories of service only:- Care home with Nursing:- Old age not falling within any other category (OP) 83, Physical Disability (PD) 5, All service users falling within the category PD will be aged 50 years or over One named service user within the category of PD who is under the age of 50 may be admitted into the home named in variation dated January 2006 One named service user may be admitted within the category DE(E) named in variation dated 19/2/07 The maximum number of service users who can be accommodated within the home is 88. 28th June 2007 Date of last inspection Brief Description of the Service: Charnwood is a registered care home providing nursing and residential 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 62 single rooms nine of which are en-suite and 12 double rooms one of which is en-suite. All bedrooms are fitted with an alarm call system and are suitably furnished. There is one large lounge within each unit, incorporating a designated dining area. There is a pleasant garden area with access for residents with impaired mobility. The current weekly fees are as follows: Residential care £294 for social services funded service users and £400 for private service users. For residents who require nursing care £360 plus the nursing contribution for social services nursing service users and £440 plus the nursing contribution for private nursing service users. These fees do not include the following - podiatry, hairdressing, toiletries and newspapers. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One inspector conducted the unannounced visit. The main method of inspection used was called ‘case tracking’ which involved selecting residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The manager, two members of staff and two visitors to the home were spoken with as part of this visit. Documents were read as part of this visit and medication management was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken which included a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. A range of additional information was used to determine the outcome of this visit. Ten “have your say” surveys were sent to residents at the home together with ten surveys for the resident’s relatives, carers and advocates. Only 10 of the surveys were returned to CSCI. Information provided by the registered provider within an Annual Quality Assurance Assessment (AQAA) was also utilised to inform the inspection process. The quality rating for this service is 2 star this means the people who use this service experience good quality outcomes. What the service does well: Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 6 The needs of the residents are identified through effective pre admittance assessments. Resident’s healthcare needs are recorded and met. Medication is well managed. Residents are afforded appropriate levels of privacy and dignity. The majority of the homes environment is pleasant, comfortable and clean. Recreational activities are provided to residents and opportunities are available for residents to interact within the broader community. Residents benefit from the provision of an appealing balanced diet and are able to have snacks and drinks as they wish. Complaints and concerns are effectively managed and staff have received training in whistleblowing procedures and the recognition of abuse. The home is well managed and a resident’s consultation process is performed to provide residents and their relatives with the opportunity to contribute to developments within the home. The health, safety and welfare of residents is promoted through effective routine maintenance. What has improved since the last inspection? What they could do better: Bathroom and toilet facilities could be improved and upgraded. Staff could receive yearly training updates in all instances. The storage facilities for wheelchairs and hoists could be improved. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 7 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 Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 8 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.V366860.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The holistic needs of the residents are identified through effective pre admittance assessments thus ensuring the facilities and services at the home can meet the resident’s needs. EVIDENCE: A Service Users Guide (SUG) is provided to all residents or their representatives, which provides good information about the facilities and services provided. A case tracked resident confirmed that a service users guide was provided on admission. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 10 The resident’s pre inspection survey asked residents, “did you receive enough information about this home before you moved in, so you could deicide if it was the right place for you?” the response received by the CSCI stated, “yes”. The survey for relatives carers and advocates asked, “do you and/or your friend get enough information about the care home to help you make decisions?” the response received by the CSCI stated, “usually”. Information provided with the AQAA stated, “We carry out a comprehensive pre admission assessments prior to admission to the home. The case tracked residents care-planning documentation showed that the assessments had been performed which included assessments from Social Services departments. The pre admittance assessment process provides the opportunity to identify the potential residents needs in relation to equality and diversity to ensure the assessment process adheres to non-discriminatory practice. The preadmittance assessments were well organised and stored securely to protect the resident’s confidential information. The acting manager said that residents or their representatives are encouraged to visit the home before gaining residency to determine the suitability of the service in meeting their needs. This was confirmed by a resident who said, “my niece and nephew visited the home prior to me coming in, and I feel lucky to be able to live in such a nice home”. Intermediate care services are not provided at the Home Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. Resident’s healthcare needs are recorded and met. Medication is well managed and residents are afforded appropriate levels of privacy and dignity. EVIDENCE: The resident’s pre inspection survey asked residents “do you receive the care and support you need?” the response received by the CSCI stated, “usually”. The survey for relative’s carers and advocates asked, “do you feel the care home meets the needs of your friend/relative?” the response was “usually” and commented “the staff are good”. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 12 Information provided within the AQAA stated “Service users undergo various assessments and our care plans are based on Activities of Daily Living, this includes falls, pressure area care, nutrition, mobility, dependency, continence and risk assessments amongst many others. Service users are involved in their care plan and monthly reviews are carried out to ensure they are still relevant. A comprehensive review is carried out with the service user and other involved parties such as family or health professionals either three or six monthly”. An examination of the case tracked care planning documnantation confirmed the information within the AQAA. The care plans were well organised and stored securely to promote the residents privacy. The resident’s pre inspection survey asked residents “do you receive the medical support you need?” the response received by the CSCI stated, “yes”. Care planning records showed and residents confirmed that they have access to members of the multi-disiplinary health team such as General Practitioners, District Nurses,Podiatrists and Opticians. Residents spoken with said that they receive their medication on time and are always provided with drinks to take their medication. Information provided withi the AQAA stated “Nursing staff and senior care staff who handle medication attend training sessions as well as in house training in the safe handling of medications”. Staff confirmed that they had recived the training from a large pharmaceuticl retailer and medication training certificates were available for inspection. Medication Administration Records (MAR) were examined, the MAR charts had no gaps present and medication administration was recorded effectively. Medication, which requires refrigeration, was stored within a secure fridge. The temperature within the medication fridge is recorded twice daily and was within the required 2-8 degrees centigrade range. The resident’s pre inspection survey asked residents “do staff listen and act on what you say?” the response received by the CSCI stated, “yes”. Residents were asked if they received the care and support they need in a respectful manner. Responses included “definitely, the thing I like about this place is that the staff are very helpful and friendly, whenever I have wanted anything its always provided” and “Staff are very nice, our respect is always promoted, we are always spoken to in a considerate manner and we never feel Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 13 rushed by the staff” and “we do not have to wait for long periods of time to receive attention”. Residents said that the home provides flexible support and confirmed that their respect and dignity is always promoted whilst performing personal interventions. Residents also confirmed that they have control over their lives and can make independent decisions in relation to their daily routines. Visitors said that the staff very welcoming and respectful at all times. They said that they had never witnessed anything that gave them cause for concern. The visitors also said they are kept fully informed of any developments in relation to their relatives health and wellbeing. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 14 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. A range of recreational activities are provided to residents and opportunities are available for residents to interact within the broader community. Residents benefit from the provision of an appealing balanced diet and are able to have snacks and drinks as they wish. EVIDENCE: Information provided within the AQAA stated, “We have an activities organiser employed for thirty hours a week and another 10 hours which we can be flexible with. She offers a wide range of activities which are tailored to suit individual needs”. The survey for residents asked, “are activities arranged at the home that you can take part in? The responses received by the CSCI stated, “sometimes”. The relatives survey asked “what do you feel the care home does well, comments included “provide motivation for residents to join in”. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 15 A wide range of social activities were advertised on a notice board in the foyer of the home. Residents said that social activities are provided, which includes fashion shows, bingo, seasonal celebrations, Christmas Pantomime, a summer fair, guest entertainers and a range of board games. Residnets also said they can utilise a mini bus to access trips to local garden centres, coffee shops, Arnold market, Victoria centre, white post farm and river trips from Newark. Religious interventions are also provided and residents confirmed that staff respect their choice if they do not wish to participate in the planned social activities. The acting manager and care staff stated that an open door policy is encouraged at the home and that resident’s family and friends can visit as they wish. Residents and visitors confirmed the open access and stated that that the staff at the home always makes the visitors very welcome. Information provided within the AQAA stated, “A four weekly menu is in place which is currently being upgrading to the “Nutmeg system” which will help ensure that food provided is nutritionally balanced”. The survey for residents asked, “do you like the meals provided at the home”. The responses received by the CSCI stated, “sometimes”. Residents spoken with said, “ We always have a choice of food and its always very nice, hot and well presented” and “ generally good, we are always provided with a choice, at least two choices sometimes more”. Residents also confirmed that they could have a drink or snack whenever they wish. We observed interactions between staff and residents at meal times. The care staff helped residents who require assistance to eat in a respectful, unrushed manner thus promoting the residents respect, dignity and comfort. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are effectively managed thus promoting the safety of the residents. Staff have recived training in whistleblowing procedures and recognition of abuse. EVIDENCE: The residents survey asked “do staff listen and act on what you say?” The response received by the CSCI stated, “yes”. A complaints procedure is on display in the foyer of the home and residents and their representatives are given the complaints procedure within the Service Users Guide. Residents spoken with said they felt safe in the home and felt confident that they could report any concerns to the acting manager or the care staff. We asked visitors to the home if they know what to do if they were not happy with the service & would they be confident enough to make a complaint. The visitors said, “We would speak to the acting manager or one of the seniors, we Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 17 have no cause for concern but believe that if we did have any concerns, they would be addressed effectively”. The acting manager was not investigating any complaints at the time of the visit and CSCI has not received any complaints relating to the service provision at the home since the last unannounced visit. The complaints file was examined and showed that two complaints had been made since the last inspection, both of which had been documented with actions and outcomes recorded. Records showed that the acting manager had addressed an incident relating to a theft in the home. The acting manager had liased with Social Services Safeguarding Adults team and the Police to ensure the incident was investigated and appropriate actions taken to promote the safety of residents. Staff training records showed and staff confirmed that training in relation to the Safeguarding Adults is provided within the staff induction process. Staff training records showed that some staff had not received the planned yearly refresher education in Safeguarding Adults. The acting manager had identified the shortfall as a result of her auditing processes and said that the shortfall was due to “in house” trainers being promoted within the organisation. To address the issue the acting manager has arranged for two divisional trainers to attend the home to provide staff training in Abuse Awareness, Safeguarding Adults and Whistle blowing procedures. It is expected that all staff will have received the refresher training by the end of July 2008. Staff demonstrated a good level understanding of their roles and responsibilities in relation to Safeguarding Adults. Staff also said that the revised Nottinghamshire Safeguarding Adults policy is now available in the office environment should they need additional information and guidence in this area. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of the homes environment is pleasant, comfortable and clean but bathroom and toilet facilities require improvements and upgrades. EVIDENCE: Information provided within the AQAA stated “We encourage service users to personalise their rooms by bringing their own furniture and other belongings with them into the home, this helps maintain feelings of self worth and hopefully makes the transition easier from home to residential care”. Resident’s bedrooms were homely, safe and personalised with many personal possessions such as family pictures, small items of furniture, a television, radio and ornaments to meet their needs. The bedrooms were well maintained, clean and fresh. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 19 The resident’s pre inspection survey asked residents “ is the home fresh and clean?” the responses received by the CSCI stated, “usually” All the residents spoken with were very satisfied with the standard of cleanliness in the home and confirmed that their bedrooms are cleaned on a daily basis, as are the communal areas. A resident said “ I am very satisfied with all the areas, the cleaner comes in every day, its dust free, its lovely”. The homes internal environment, which included the dining room and the lounge area, were clean, fresh and homely throughout. We found that some of the bathroom facilities would benefit from an upgrade and redecoration. In addition a resident expressed a concern that a downstairs bath had been out of commission for some time. The acting manager stated that it has been arranged for the bath to be completely replaced in the near future at part of a planned refurbishment programme. The acting manager also said that an action plan has been devised to upgrade all the bathrooms to ensure they are more ‘homely’ and to make them less clinical in appearance. It is the intention that bathrooms and shower rooms will be “themed” and the acting manager has commenced purchasing items to help achieve this. The acting manager stated that the process should be completed within the next six months. It was noted that wheelchairs and equipment designed to aid mobility were being stored inappropriately in some bathroom areas and on corridors, which could present a potential risk to residents. The acting manager said that she is currently exploring alternative storage options for wheelchairs and hoists and plans to have two designated areas provided to store the wheelchairs and hoists. Staff are provided with, and were using, gloves, aprons and anti-bacterial hand wash to promote infection control within the home. A member of staff demonstrated a good knowledge of the principles of infection control within care home environments. The well-maintained garden area is accessible to residents with impaired mobility. The garden area has a range of garden furniture for residents and visitors use in the summer months. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 20 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. Residents needs are met by the number and skill mix of staff at the home but staff have not received yearly training updates in all instances which has the potential to compromise residents health and wellbeing. EVIDENCE: The resident’s pre inspection survey asked residents “ are staff available when you need them?” the response received by the CSCI stated, “sometimes” All residents spoken with expressed satisfaction with the staffing levels at the home. Residents said, “Sometime you have to wait but not for very long, the staff are very good and always attend” and “all the staff are very good at what they do”. Information provided within the AQAA showed that the service has exceeded the required level of staff with or working towards a National Vocational Qualification (NVQ) in care. A revised induction programme has recently been initiated which covers the principles of care, the organisation and the role of the worker, maintaining Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 21 safety at work, effective communication, responding to abuse and neglect and staff development. The revised induction package will take up to twelve weeks to complete and all newly employed staff will be required to complete the induction process as will staff who have commenced employment at the home within the past twelve months. We were provided with staff training records, which showed that some staff had not received some yearly refresher training. As mentioned earlier in the report the shortfall was due to “in house” trainers being promoted within the organisation. The acting manager was aware of the shortfall and has initiated a training plan with an expectation that all staff training will be up to date by the end of July 2008. The training programme will include Fire awareness, the Control of Substances Hazardous to Health (COSHH), Abuse Awareness, Safeguarding Adults, Whistle blowing, Food Hygiene, Health and Safety and Nutrition. To support the existing home trainers, and to achieve the training needs of the staff, two divisional trainers will be utilised, initially for four full days but with an option to increase this if necessary. The acting manager also provided documentary evidence that she is in the process of recruiting two more “in house” home trainers who will be expected to attain a recognised City in Guilds certificate in teaching. Staff recruitment records showed that members of staff had only commenced employment once satisfactory Protection of Vulnerable Adult (POVA) checks and Criminal Record Bureau (CRB) checks have been obtained, together with two satisfactory references, thus promoting the safety and wellbeing of residents. The recruitment documentation was somewhat disorganised, it is recommended that the documentation be reorganised to address the issue. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a person who is fit to be in charge. A resident’s consultation process is performed to provide residents and their relatives with the opportunity to contribute to developments within the home. The health, safety and welfare of residents is promoted through effective routine maintenance. EVIDENCE: The acting manager has been in employment at Charnwood since March 2008 and is in the process of applying for registration with the Commission for Social Care Inspection. The acting manager has worked within health care Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 23 environment for many years and demonstrated a good knowledge of her managerial roles and responsibilities. The acting manager has a Registered Managers Award and has completed a City in Guilds advanced care management course. Staff said that the acting manager was very approachable and professional. Residents commented, “the home is well run”, and “I feel lucky to live in such a nice place”. The acting manager said that she ensures a quality service is maintained by carrying out extensive monthly audits, which examine all aspect of service provision. The results of the audits are analysed and action plans are devised to address any areas of concern. Records were evident to support this. To ensure that residents and their representatives have the opportunity to express their views the acting manager said that monthly residents and relatives meetings are performed. Residents confirmed that the meeting take place and a report of the residents meetings is displayed on the notice board for future reference. To further assess the quality of service provision at the home the acting manager ensures that questionnaires are sent out to residents, relatives, staff and other visiting professionals to gain an insight into their satisfaction levels in relation to service provision. Information provided with the AQAA statted “Service users financial records are monitored by the Home Manager and the home administrator, these are recorded both electronically and on paper so that service users or their family/appointee have access to them easily if required. All monies received or spent are receipted and all transactions have double signatures. All records are kept securely”. We examined accounting sheets and they correlated with finances available. One resident confirmed that he had money in safekeeping which he could access this at any time. Resident’s health safety and wellbeing is promoted by the provision of effective routine maintenance and documentation was available to show that annual gas testing, mains electrical testing, Legionella testing, hoist and mobility checks had taken place. Staff were observed to be working in a safe manner and assisted residents with impaired mobility in a professional and competent manner. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 24 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 3 x x x 3 Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 25 No 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 OP19 Regulation 23 Requirement To promote the health and well being of residents the registered person must ensure that the planned up grade of the bathroom and shower facilities is undertaken as a matter of priority. To promote the health and well being of residents the registered person must ensure that hoists and wheelchairs are stored appropriately. To promote the health and well being of residents the registered person must ensure that staff revive the planned yearly refresher training programme. Timescale for action 31/08/08 2 OP19 23 31/08/08 3 OP30 30 31/08/08 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 Refer to Standard OP29 Good Practice Recommendations It is recommended that recruitment documentation be DS0000026425.V366860.R01.S.doc Version 5.2 Page 26 Charnwood Care Home reorganised to ensure it is maintained in a satisfactory manner. Charnwood Care Home DS0000026425.V366860.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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