Inspection on 29/11/05 for Charnwood House

This inspection was carried out on 29th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charnwood House 29/04/08

Charnwood House 30/04/07

Charnwood House 31/05/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood House 2 The Avenue Fairfield Stockton-on-Tees TS19 7EY Lead Inspector Julia Connor Unannounced Inspection 29th November 2005 11:35 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.V250077.R01.S.doc Version 5.0 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.V250077.R01.S.doc Version 5.0 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 - over 65 years of age (16) registration, with number of places Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named individuals who are under the age category are allowed to reside in the home. 28th June 2005 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. There is a small car park at the front of the home. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over two days, the first day of the inspection commenced at 11.35 a.m. and concluded at 3.10 p.m. The second day of the inspection commenced at 9.35 a.m. and concluded at 11.55 a.m. Five Residents’ and three members of staff were spoken to during the inspection. Five comment cards from family members/friends were returned to the Commission for Social Care Inspection. The carpet in the dining room had been damaged to due a leak in the roof, this resulted in the carpet having shrunk and although repair had been attempted the edges of the carpet were not meeting which left a ridge which could have resulted in a Resident or member of staff tripping and was therefore a health and safety issue. An immediate requirement was issued which required the Responsible Individual to take immediate action to make the area safe. On the second day of the inspection the area had been made safe. What the service does well: What has improved since the last inspection? Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 6 Six new beds and two new mattresses have been purchased and the roof repaired over the kitchen, dining room and television lounge. Two toilets and several new light fittings have also been purchased. 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 House DS0000000004.V250077.R01.S.doc Version 5.0 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.V250077.R01.S.doc Version 5.0 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 Residents’ have their needs assessed prior to moving into the home. EVIDENCE: There was evidence in the care documentation that Residents’ needs were assessed prior to admission to the home and that the Resident or their next of kin had been involved in the assessment. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 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): 9 and 10 Medication is dispensed appropriately and Residents’ are protected by the home’s policies and procedures for dealing with medication. Residents’ are treated with respect and their privacy upheld. EVIDENCE: There is a policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. Only senior members of staff, who had received training in the safe handling of medication, dispense medication. A new BNF (British National Formulary) would be beneficial to ensure the staff has access to up to date information regarding medication. A random audit of the controlled medication would be good practise. The Residents’ who spoke to the Inspector stated that the staff always treated them with respect and dignity. The rapport observed between the Residents’ and staff was kind and respectful. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 It would be beneficial if there were a more structured approach in providing activities, which could include individual work with Residents’. Residents’ maintain contact with their family and friends and are encouraged to make choices in their every day lives. EVIDENCE: The Residents’ who spoke to the Inspector stated that there were activities but they did not have to join in if they did not wish to. One Resident informed the Inspector that she liked to watch television or read her books and magazines. Another Resident stated that she liked to play bingo. The male Resident who spoke to the Inspector stated that he liked to watch the television. The staff informed the Inspector that they took turns at providing activities but most of the Residents’ did not wish to participate or their attention span was limited. It would be beneficial if there were a more structured approach in providing activities, which could include individual work with Residents’. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 11 Residents’ informed the Inspector that they received visits from family members and the staff always made them welcome. On both inspection days there were visitors in the home. Residents’ stated that although the staff encouraged them to do as much for themselves as possible they were there should help be needed. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 12 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): Standards 16 – 18 were not assessed during this inspection. EVIDENCE: Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 13 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, 25 and 26 There were areas within the home that were not well maintained which resulted in the home not always proving a safe environment for the Residents’ to live in. The home is not always as clean as it should be and they were areas that had an offensive odour. EVIDENCE: On the first day of the inspection a tour of the home was made with a Senior Care Assistant. The carpet in the dining room had been damaged to due a leak in the roof, this resulted in the carpets having shrunk and although repair had been attempted the edges of the carpet were not meeting which left a ridge which could have resulted in a Resident or member of staff tripping and was therefore a health and safety issue. An immediate requirement was issued which required the Responsible Individual to take immediate action to make the area safe. On the second day of the inspection the area had been made safe. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 14 There were bedrooms that were not as clean as they should be for example in one bedroom there was a layer on dust on the furniture and windowsill and carpets required hoovering and many required a deep clean. There were bedroom windows that required cleaning. There were carpet edges that needed to be re-glued to ensure the Residents’ safety. There were bedrooms, toilet areas and one lounge that had offensive odours. There was a bedroom window that had a broken window latch and bedroom windows that had no restrictors in place – an immediate requirement was issued due to the health and safety aspect. On the second day of the inspection the latch and window restrictors had been replaced. The front lounge was very cold and was therefore not useable by Residents’ and visitors. There was a portable heater in a bedroom to provide heat, as the room was very cold. Unfortunately this heater had to be removed, as it was a health and safety issue in that if the Resident had fallen against it s/he would have sustained a severe burn. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 15 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 The Registered Manager should review the needs of the Residents’ to ensure sufficient staff is on duty. EVIDENCE: Two of the Relative comment cards recorded that in their opinion there was not always sufficient staff on duty to meet the needs of their relative’s, for example if a carer was required to escort a Resident to an out patient appointment the cleaner or cook had to become a carer. The duty rota was audited and showed that there was one senior care assistant and one care assistant on duty from 8 a.m. to 8 p.m. and one waking care assistant and one sleeping care assistant for the night shift. Staff who spoke to the Inspector stated that there was sufficient staff on duty to meet the Residents’ needs. These staff stated that if they had more than one role at the home they did not carry out both roles at the same time, for example if they were working as a cook or cleaner they would not deliver any personal care. The Residents’ who spoke to the Inspector were unable to voice an opinion on whether there was sufficient staff on duty to care for them. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 16 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): 33, 35 and 38. There is a quality audit document, which is accessible to those who wish to read it. The Residents’ financial interests are safeguarded by the policies and procedures in place within the home. The health and safety of the Residents’ and staff are promoted and protected. EVIDENCE: Each Resident has his/her own money wallet. A record is kept of all the money a Resident receives and spends and receipts are obtained and kept in the individual wallet. There are two signatures when money is deposited or withdrawn. There is a policy and procedure in place for Residents’ finances. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 17 There is a quality assurance and quality monitoring system in place within the home. The audits cover the different departments within the home e.g., the kitchen and the environment. An audit of the homes Health and Safety Policies and Procedures was undertaken. Staff has received health and safety training e.g. Manual Handling and Fire. The Manager recorded in the Pre-inspection questionnaire that equipment was maintained as required, for example the hoists’ were serviced on July 2005 and the fire equipment was serviced on 17/3/2005. Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 18 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 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 19 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 OP19 OP25 OP26 Regulation 23 Requirement The Registered Manager must keep the home in a good state of repair – see the main body of the report for details. The Registered Manager must keep the home free of offensive odours. Timescale for action 31/03/06 2 16 28/02/06 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 Refer to Standard OP9 Good Practice Recommendations A new BNF (British National Formulary) would be beneficial to ensure the staff has access to up to date information regarding medication. A random audit of the controlled medication would be good practise. It would be beneficial if there were a more structured approach in providing activities, which could include individual work with Residents. The Registered Manager should review the needs of the Residents’ to ensure sufficient staff is on duty. 2 3 OP12 OP27 Charnwood House DS0000000004.V250077.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 House DS0000000004.V250077.R01.S.doc Version 5.0 Page 21 - 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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