Inspection on 29/04/08 for Charnwood House

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Good service.

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 House 30/04/07

Charnwood House 31/05/06

Charnwood House 29/11/05

Charnwood House 28/06/05

Charnwood House 18/11/04

Charnwood House 23/04/04

Similar services:

Eastwood

Farmborough Court

Connolly House

Falstone Court Nursing Home

Craghall Residential Home

Elaine House

Close House

Dovecote Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood House 2 The Avenue Fairfield Stockton-on-Tees TS19 7EY Lead Inspector Val Daly Key Unannounced Inspection 29th April 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charnwood House DS0000000004.V364798.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 House DS0000000004.V364798.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood House Address 2 The Avenue Fairfield Stockton-on-Tees TS19 7EY 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) 01642 884001 Mrs Mary Elizabeth Serwan Mr Rajman Serwan Mrs Mary Elizabeth Serwan Care Home 16 Category(ies) of Dementia (16) registration, with number of places Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Dementia - Code DE, maximum number of places: 16 The maximum number of service users who can be accommodated is: 16 30th April 2007 Date of last inspection Brief Description of the Service: Charnwood is a care home providing personal care for older people with mental health needs. It is a large Victorian/Edwardian detached house providing both single and shared accommodation for 16 Residents. There are 12 single bedrooms and 2 double bedrooms. The single bedrooms are a minimum of 10 sq.m and the double bedrooms are a minimum of 16 sq.m. There is a passenger lift giving access to the upper floor. There are three lounges (one of which is for those Residents who smoke) and a large communal dining room. The current scale of charges is £405.00 per week. Additional charges include Chiropody, hairdressing, dry cleaning and personal items. There is a small car park at the front of the home. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality star rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was a key unannounced inspection and was completed by an inspector in two inspection days. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A number of records were looked at including assessments of people who use the service and plans of care, staff recruitment records, complaints and maintenance records along with the annual quality assurance assessment. One person, who uses the service, two members of staff and the manager, were engaged in discussion about living at Charnwood. The manager had completed an Annual Quality Assurance Assessment prior to the inspection. The AQAA is the services self-assessment of how they think they are meeting the National Minimum Standards. This information is received prior to the inspection and it is then used as part of the inspection process. On the days of the visits the manager provided the information and documentation required. The Commission for Social Care Inspection sent a number of surveys to the home for relatives of people who use the service to complete. Two were completed and returned. Comments received can be read within the report. This was a positive inspection; people were open and friendly and welcomed discussion about the home. What the service does well: The care plans examined were very informative and information was also included following on from the life history on how the person likes to spend their day. The information was very detailed for all aspects of daily life, for example how one person likes to be shaved and another how they particularly preferred their food cutting up. Within the care files there was also ‘aims and objectives of the placement’ which described the whole plan of care, what the person was able to do and areas help is needed. There was evidence that the person’s health care needs were being met. Risk assessments were in place Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 6 where needed, for one person, going out on their own. The assessment stated who was involved in the decision making and why it was made. The plans of care are agreed and signed by either the person who uses the service or their relative. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Charnwood House DS0000000004.V364798.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 House DS0000000004.V364798.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): 3&6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have their needs assessed. EVIDENCE: Care managers carry out assessments prior to a person moving into the home to ensure their needs can be met. The home manager also carries out her own assessment, meeting with the prospective person, either in his or her own home or in hospital. This information was viewed in the files of two people who use the service. The assessment documentation was comprehensive and covered the activities of daily living along with the person’s medical, physical and mental health history. A life history of the person is taken, which is very informative and can assist with the social care plan. Two Relative comment cards stated that they had enough information before deciding if the home was right for their family member. The home does not provide intermediate care. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Two care files were examined and they each contained an individual plan of care. The plans were evaluated and reviewed monthly. Information was also included following on from the life history on how the person likes to spend their day. The information was very detailed for all aspects of daily life, for example how one person likes to be shaved and another how they particularly preferred their food cutting up. Within the care files there was also ‘aims and objectives of the placement’ which described the whole plan of care, what the person was able to do and areas help is needed. There was evidence that the person’s health care needs were being met. Risk assessments were in place where needed, for one person, going out on their own. The assessment stated who was involved in the decision making and why it was made. The plans of care are agreed and signed by either the person who uses the service or their relative. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 10 Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. For people wishing to manage their own medication a risk assessment and management process was in place. Staffs who administer medication had received safe handling of medication training. This was confirmed in staff training records and during staff interviews. Comment cards from relatives of people who use the service stated ‘the home is providing caring and personalised attention with an intimate family style atmosphere. It is easy to know all the carers by name and responsibilities are well defines and understood. ‘As Charnwood is a small care home it provides a family environment and gives the immediate impression of a welcoming and cosy place, while giving expert professional help to the mix of the residents’. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their lifestyle. A variety of food is offered. EVIDENCE: Activities in the home take place on a daily basis dominoes and afternoon films being popular. There is also a motivation class every month, and notes are kept about who attended the session and their enjoyment. One person who uses the service enjoys a visit to the local pub once a fortnight with one of the providers. Information about how people spend their day is included in the care plans. Religious services take place in the home and residents are able to receive communion if they wish. Relatives and friends are welcome to visit at anytime. Comment cards from relative of people who use the service stated ‘We keep in touch by telephone and visits’. We live at a distance from the home and feel confident that our family member is in good hands and appears happy and busy under the circumstances’. The home has a secure garden area for people to enjoy in the better weather, which is well tended and full of colourful flowers and bushes. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 12 The menu showed that a variety of food is offered to residents and more alternatives are available. Staff in the home knows the people who live there well and their likes and dislikes. The cook does home baking daily. People in the home generally eat their meals in the dining area but they are able to eat in their rooms if they wish. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain and the home has a procedure in place, however this needs to be clearer. Training for staff in adult protection has taken place, keeping people who use the service safeguarded. EVIDENCE: One person interviewed said that they would talk to a member of staff if they had any worries. Comment cards from relatives of people who use the service stated ‘We have not raised any concerns but I would go to the manager or a member of staff if we needed to’. The manager said she would add this information to the policy. There had not been any complaints made to the home since the previous inspection. The home has a whistle blowing policy and an adult protection policy in place. This policy required further development to show how an allegation of abuse would be followed through. There was evidence in the staff training file to show that staff had received training in Adult Protection’. During interviews with staff Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 14 they confirmed they had received training were aware of the procedure to follow in the case of suspected abuse. Charnwood House DS0000000004.V364798.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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Charnwood is comfortable, homely and well maintained. EVIDENCE: A tour of the home was carried out. People’s bedrooms contained personal possessions and were comfortable and homely. Re decoration and refurbishment is ongoing. Since the previous inspection curtains and flooring had been replaced in a number of bedrooms. There were also some new armchairs in the main lounge. The provider continues to replace the old style beds. The home was clean and tidy without any odours. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The vetting and recruitment practices are robust. Staffs is trained and qualified and relevant information that safeguards people who use the service is in place. EVIDENCE: The home has a rota in place, which is flexible for the needs of the people who use the service. There is a policy and procedure in place for the recruitment of staff. Staff records showed that the required information, references and CRB checks were in place prior to staff commencing work in the home. The manager plans and organises the staff training. New staffs receive induction training using the Skills for Care Induction Standards, which may take up to six months. There are ten carers employed and they all have achieved NVQ level 2 and three have also completed NVQ level 3. Since the previous inspection staff had undertaken training in many areas such as NVQ, Food Hygiene, Fire Safety, Nutrition and Health, Safeguarding, Infection Control, the Mental Capacity Act and seven staff have Safe Handling of Medication. At the time of the inspection the manager and two senior carers were undertaking a course in IT skills. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 17 A relative comment card stated’ The variety of staff offer different skills and my family member benefits from their experience and expertise’. ‘My family member has been here a year and has had excellent care and friendship from the staff’. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home regularly reviews aspects of its performance through a good programme of self-review, which include seeking the views of residents, staff and relatives. Finance systems are robust. EVIDENCE: One of the providers has been the manager of the home for many years. She is qualified and competent to run the home. The manager has a quality assurance system in place and sends out surveys annually. An action plan is formulated if any issues or concerns are raised. Formal meetings for staff and people who use the service are not held, however one to one or small group discussions take place regularly. Two carers interviewed felt that the manager listened to their thoughts and points of view. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 19 Records showed that the home has a formal supervision and appraisal system for staff in place and the documentation was found to be up to date. Resident’s finances and records were kept appropriately with signatures in place. A number of Health and Safety records were examined. Documentation showed that water temperatures are taken and documented monthly, however Health and Safety Executive requires that these are taken and recorded weekly for baths and showers. Staffs receive regular training in Health and Safety and there is a full training plan in place. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 13 (c ) Requirement Hot water temperatures in bathrooms and showers must be taken and recorded weekly to ensure the safety of the people who use the service. Timescale for action 30/06/08 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 OP16 Good Practice Recommendations The complaints procedure should include information regarding the Contracts and Commissioning Department of the Local Authority. Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Charnwood House DS0000000004.V364798.R01.S.doc Version 5.2 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. 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