Inspection on 30/04/07 for Charnwood House

This inspection was carried out on 30th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Charnwood House 29/04/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charnwood House 2 The Avenue Fairfield Stockton-on-Tees TS19 7EY Lead Inspector Belinda Parker Key Unannounced Inspection 30th April 2007 09:00 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.V336819.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.V336819.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 - over 65 years of age (16) registration, with number of places Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named individuals who are under the age category are allowed to reside in the home. 31st May 2006 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 £347.00 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.V336819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place at 9am on the 30th April 2007 over a period of 5 hours. During the visit we spoke to the people who use the service, the manager and the staff. Two relatives returned questionnaires sent out prior to the visit. One visitor came into the home during the visit but declined the opportunity to speak to the inspector. A tour of the building was undertaken. A number of documents and records were examined. 5 of the seven requirements made at the last inspection have been met. 11 people are residing in the home at present. What the service does well: What has improved since the last inspection? Since the last inspection there has been some further refurbishment within the home providing a more comfortable and pleasing environment for the people who live there. 100 of care staff in the home have achieved NVQ2 in Care. Training for staff is ongoing to ensure they are equipped with the appropriate skills to deliver a good standard of care the people who live in the home. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 6 An external motivational group visits every two weeks and involves the people who live there in a range of activities. The manager said people are not forced to join in it is there choice if they wish to participate. 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.V336819.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.V336819.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 , (St 6 not applicable ). The home does not provide intermediate care. Quality in this outcome area is “ good”. This judgement has been made using available evidence including a visit to this service. There is a clear process for admission to the home that involves the service user, relatives and other health professionals. This process ensures the home can meet the individual needs of the service user. EVIDENCE: Evidence from three residents files examined confirms that the assessment prior to admission is conducted professionally and includes the resident, their family and other health professionals involved in their care. The manager said no service user is admitted to the home without a full assessment to ensure the needs of the person can be met by the home. The manager said where residents are admitted from a different cultural background specialist and additional information is documented in the original assessment to ensure that their specific needs are met. Charnwood House DS0000000004.V336819.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 and 10 Quality in this outcome area is “ good”. This judgement has been made using available evidence including a visit to this service. The health and personal needs of the people living in the home are met. The good health of people living there is promoted through the safe handling of medication. People living in the home are treated with respect and dignity. EVIDENCE: Three files examined by the inspector were comprehensive and included a personal plan that is reviewed on a regular basis but the evaluation was limited in information therefore not providing staff with a full overview of any changes to the service user’s personal care that may have occurred since the last evaluation. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 10 Care plans included evidence to show where service users’ lacked capacity relatives had signed as to their agreement with the care plan and had been involved in reviews held at the home by social services. Visits by other health professionals are documented in the care plan. Since the last inspection the home has changed their pharmacy supplier from Boots MDS to Rowland’s MDS. The manager said all staff had received training from the new pharmacy provider. Staff spoken to during the visit confirmed that they had attended training on the safe handling of medicines. Policies and procedures for dealing with medication were reviewed within the last year. A sample of Marr sheets examined presented as accurate and up to date. Due to service users lacking capacity care plans included agreement from the person or their relative giving the home staff permission to administer their medication. A locked cabinet was available in individual bedrooms for storage of medication. People spoken to during the visit confirmed that staff treat them with respect and dignity. One service user commented, “ They are all good girls”, another person said, “ You can’t get much better than this”. A staff member confirmed that when assisting residents with dressing she always offers choice of clothes and colours to ensure residents are comfortably dressed. Charnwood House DS0000000004.V336819.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 and 15 Quality in this outcome area is “ adequate”. This judgement has been made using available evidence including a visit to this service. Social activities in the home should be developed further to provide a stimulating and fulfilling lifestyle for the people who live there. People living in the home can receive visitors at any reasonable time. Residents can access external advocates if they so wish. The home provides residents’ with a nutritional and well balanced diet. EVIDENCE: Since the last inspection the manager said an external motivational group visits the home on a two weekly basis and involves the people who live there in a variety of activities. Residents are not forced to join in if they do not wish to do so. Staff said they continue with many of the activities carried out by the group. The manager said she is aware this area of care provision needs further development. A staff member spoken to said “ I have a group of four people who like to play domino’s after lunch”. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 12 One person spoken to said he visits the pub regularly with the owner and they have a pleasant evening. He said, “ I like to have three pints of Fosters”. A relative who completed a questionnaire commented on the limited choice of activities available. The manager said many of the people living in the home do not receive visitors but people who have relatives that visit regularly are welcome to visit at any time. A relative visiting during the inspection declined the opportunity to speak to the inspector. A resident living in the home from a different cultural background initially was provided with the services of an interpreter. But the staff have developed knowledge of the resident’s language from speaking to relatives and can communicate with the resident quite well. A staff member spoken to during the visit demonstrated key phrases she had learnt that she regularly put into practice when supporting the resident. The dining area was spacious and tables were set appropriately. One staff member said residents are encouraged to eat their meals independently but help is given if required. A service user from a different cultural background was observed eating her meal with chopsticks, which is the method traditional to her culture. A daily menu was displayed in the dining room. A staff member said an alternative to the main meal choice is always available. A resident commented, “ The food is tasty here”. The meals were presented well and portion size was good. Care plans sampled included a plan for one resident who needed encouragement to eat a full meal. Discussion took place with the manager as to developing care plans to include a nutritional assessment. Staff have recently completed a course on Nutrition for older people. Charnwood House DS0000000004.V336819.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 and 18 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear enabling the people living in and visiting the home to make their views known. Service users are protected from abuse through thorough recruitment procedures and staff training. EVIDENCE: The home has a clear complaints procedure in place to enable residents and their relatives to make their views known. A copy of the complaints procedure is included in the service user guide. Evidence is available to show that all staff have completed POVA training. Two staff members are commencing a refresher course in May 2007. A staff member spoken to during the visit demonstrated that she was aware of the different kinds of abuse that can occur and was able to demonstrate the referral process in the event of an incident occurring in the home. A sample of staff personnel files examined included all the necessary information to safe guard the people living in the home. The majority of staff have had their CRB renewed since the last inspection. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 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. 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. Further refurbishment is required to provide the people who live there with a high standard of comfort. EVIDENCE: Since the last inspection further refurbishment and redecoration has taken place. The seating in the lounge has been replaced and decoration of some bedrooms and communal areas completed. The manager said the local authority has awarded a grant to the home that is to be used to continue with replacing bedroom and communal carpets and the purchase of a new television for the comfort of residents. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 15 The home is traditional in style and discussion took place with the manager as to the future replacement of old style hospital beds in some bedrooms. Many residents have personalised their bedroom in their own style. An enclosed colourful garden area is available to residents, the lounge faces onto the garden providing a pleasant outlook. The home is free from any offensive odours. Charnwood House DS0000000004.V336819.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 and 30 Quality in this outcome area is “ good”. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by staff employed in adequate numbers and skill mix. Staff are equipped with the appropriate skills and abilities to meet the needs of the people living in the home. A thorough recruitment process is followed for the protection of the people who use the service. EVIDENCE: Since the last inspection the staffing structure has been reviewed. A senior carer is available in the home when the manager is off duty. A sample duty rota provided showed that staff are employed in adequate numbers to meet the needs of the people who live in the home (11 residents living in the home at present). One member of staff who is employed as a cleaner also works additional hours as a carer in the event of staff sickness or absence. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 17 Since the last inspection all staff working in the home have achieved NVQ2 in Care. Two staff members spoken to said training is always being arranged and they have learnt a lot. One staff member said, “ The manager is a stickler for training. But I want to learn”. Staff personnel files confirmed that staff attend training to update their skills on a regular basis. A sample of staff personnel files examined showed that a thorough recruitment process is followed to ensure the protection of the people who live there. Since the last inspection evidence was available to show that many staff have had a new CRB check carried out. Charnwood House DS0000000004.V336819.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 and 38 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to this service. The manager runs the service in the best interests of the people who live there. Residents and their relatives are given the opportunity to make their views known. Residents’ financial interests are protected. Health and Safety is promoted in the home for the protection of the people who live there, work and visit the home. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 19 EVIDENCE: The manager is experienced in caring for older people with Dementia and runs the home in the best interests of the people who live there. Residents and staff spoken to confirmed that the manager always has time to speak to you. A new satisfaction questionnaire has been developed and will be sent to relatives of service users to obtain their views. The manager said many of the people living there lack capacity so formal meetings are not held in the home. The manager said she and the staff meet daily to discuss residents well being and also talk to residents regularly on a 1-1 basis. A resident spoken to confirmed this. The manager said the home only holds small amounts of money on behalf of residents. Residents who do not have relatives have their affairs managed by the local authority. An audit carried out of monies held by the home on behalf of residents was found to be recorded accurately with two signatures evident for all transactions. Receipts were available for all purchases made. On touring the home it was observed to be free from trip hazards. Health and Safety policies and procedures are in place. Records were available to show that checks of major systems and disability equipment are carried out on a regular basis. Water temperatures tested at random where found to be within the recommended guidelines of 43 degrees C. A staff member who carries out cleaning duties confirmed that she had attended COSHH training and all cleaning materials were stored in a locked facility. Evidence was included in staff personnel files to show that other H&S training had been attended by staff to ensure the protection of the people who live there, work there and visit the home. Charnwood House DS0000000004.V336819.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 2 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 X 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 House DS0000000004.V336819.R01.S.doc Version 5.2 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 OP19 Regulation 23 Requirement The registered person must continue to replace bedroom carpets and complete decoration and renewal of soft furnishings to improve standard of comfort for the people who use the service. The registered person must provide activities within the home to give people the choice of a stimulating and fulfilling lifestyle. Timescale for action 30/12/07 2. OP12 16 01/09/07 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 OP7 Good Practice Recommendations The registered person should give consideration to replacement of old style hospital beds in some bedrooms. The registered person should ensure that care plan evaluations include adequate information to enable staff to meet the changing needs of the people who live there. Charnwood House DS0000000004.V336819.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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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