Inspection on 22/10/07 for Charnwood Oaks

This inspection was carried out on 22nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Oaks 12/08/10

Charnwood Oaks 17/12/09

Charnwood Oaks 10/02/09

Charnwood Oaks 06/11/08

Charnwood Oaks 05/08/08

Charnwood Oaks 27/02/08

Charnwood Oaks 07/11/06

Charnwood Oaks 08/08/06

Similar services:

Trevayler Residential Care Home

St Marys Nursing Home

Thornham Grove

Cheaney Court Care Home

Thistle Hill Hall

Chater Lodge

Conifer Lodge

Tixover Care Home

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

CARE HOMES FOR OLDER PEOPLE Charnwood Oaks Sullington Road Shepshed Leicestershire LE2 3JN Lead Inspector Diane Butler Unannounced Inspection 22nd October 2007 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 Oaks DS0000066624.V348381.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 Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood Oaks Address Sullington Road Shepshed Leicestershire LE2 3JN 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) 0116 270 5678 info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Position Vacant Care Home 84 Category(ies) of Dementia (84), Dementia - over 65 years of age registration, with number (84), Mental disorder, excluding learning of places disability or dementia (84), Mental Disorder, excluding learning disability or dementia - over 65 years of age (84), Physical disability (12), Physical disability over 65 years of age (12) Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No persons falling within the categories DE or DE(E) to be accommodated at Charnwood Oaks when there are already 84 persons of those categories or combined categories accommodated at Charnwood Oaks No persons falling within the categories PD or PD(E) to be accommodated at Charnwood Oaks when there are already 12 persons of those categories or combined categories accommodated at Charnwood Oaks No persons falling within the categories MD (excluding Learning Disability or Dementia over the age of 50 years) or MD(E) to be accommodated at Charnwood Oaks when there are already 84 persons of those categories or combined categories accommodated at Charnwood Oaks The maximum number of persons to be accommodated at Charnwood Oaks is 84 7th November 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Charnwood Oaks is a care home for older persons, providing nursing and personal care for up to 84 older people, some of who have mental health needs, dementia and/or physical disabilities. The home was purpose built in 2006 and is owned and managed by Prime Life Limited. The home is situated in the small town of Shepshed, Leicestershire. The home is close to the main road and is easily accessible by private or public transport. Accommodation can be found on two floors which can be accessed by either stairs or passenger lift. Charnwood Oaks is divided into four units. Each unit provides the residents with their own single ensuite bedroom and communal lounge and kitchen facilities are available. The dining room is situated on the first floor of the home and residents can choose whether to use this facility or not. Current private charges are £475.00 per week and additional charges are in place for personal items such as newspapers, toiletries, and chiropody treatment. Details of what additional charges residents can expect to pay can be found in the information pack which is given to all residents either prior , or on arrival at Charnwood Oaks. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 5 A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the acting manager. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over two days in October 2007. The acting manager was on duty at the time of the inspection. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting five residents and tracking the care they received through looking at their records, speaking with them when possible and discussion with staff on duty at the time of the visit. Where communication was difficult observation was used to evidence whether care needs were being met. A further two clients and three relatives were also spoken with during the site visit. The inspector was assisted for part of the inspection by the Commission for Social Care Inspections Regional Lead Pharmacist inspector, who looked at current medication practices and procedures. Additional planning for the site visit included checking the homes service history and the last key Inspection report. The AQAA document (Annual Quality Assurance Assessment) had been requested prior to this site, this was received following the visit. What the service does well: Charnwood Oaks is a purpose built care home providing accommodation for up to 84 Residents within four separate units. Each unit offers a lounge with a small kitchen area where snacks and drinks can be prepared and assisted bathing facilities are provided. The home is extremely well maintained both internally and externally and the decoration and furnishings throughout the home are both of a very high standard and are presented in a comfortable and homely way. Choices are offered to the residents on a daily basis including when to get up and go to bed, what to eat and where and when to eat it and whether to join in the activities provided. Mealtimes are extremely flexible and snacks and drinks are also available throughout the day. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 7 All care workers spoken with had a good awareness of the residents current care needs and all residents and their relatives spoken with stated that on the whole their current care needs were being met. Care workers are appropriately trained and provide care and support in positive and dignified manner. The acting manager is aware of the procedures to follow to ensure that the residents in her care are protected and all care workers spoken with during the site visit were aware of the actions to take, should they suspect any form of abuse. What has improved since the last inspection? What they could do better: Ensure that the residents care plans and associated documents are kept up to date and accurate. Care workers need to have up to date information to enable them to care properly for the residents. Ensure that the risk assessment documentation is up to date and accurate and that it contains all the risks presented to both the resident and the staff. Care workers need to be aware of all the current risks to the residents and the actions to take to minimise those risks. Ensure that risk assessments are carried out all safe working practices. Residents living in the home need to be protected from any possible harm. Ensure that there are appropriate numbers of staff on duty at all times. Staff must be given the time to provide the necessary care and support to meet the needs of the residents living in the home. Provide more formal activities, this would enable more residents to access this resource which the home currently offers. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 8 Ensure that adequate numbers of nursing staff are available to give medication in a timely, unhurried, correct and safe way. Ensure that medication records are accurate, complete and up to date and that administration records are signed shortly after administration has been witnessed for individual residents. Ensure that when medication is administered covertly adequate safeguards are in place to ensure this is in the context of existing legal and best practice frameworks. 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 Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 9 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 Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 10 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): 1,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are appropriately assessed before moving into the home to ensure that their care and nursing needs can be met. EVIDENCE: An information pack is available to all prospective residents and their families. Included in this pack is a copy of the Statement of Purpose, a document, which provides information about the home, an introduction brochure, which includes information on their charter of resident’s rights and a copy of the Terms and Conditions for self funding residents. Details of the complaints process are also included. Prospective residents and/or their relatives are also invited to look around the home to see what facilities are available and whether it would be the right place for them to live. This was confirmed on speaking with residents and relatives visiting during the site visit. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 11 Comments received included: “I had the opportunity to look around and pick the room for my mum”. “We came and had a look around, my mum came and then my sister and I came”. The acting manager explained that all prospective residents are assessed prior to moving into the home to ensure that their care and support needs can be met. A needs assessment is completed and this document forms the basis of the residents care plan once they have moved into the home. On checking the files belonging to three residents who had moved into the home since the last inspection, two included a completed needs assessment. On discussion with the acting manager it was noted that the file without a needs assessment belonged to a resident who had recently moved from another Prime Life home and the residents needs had been assessed by them. A relative visiting during the site visit confirmed that someone had visited her relative prior to him moving in. Intermediate care is not currently provided at Charnwood Oaks. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are looked after well in respect of their health and personal care, however, risk assessments and care plans need to be appropriately completed and kept up to date to ensure that their health and welfare are not put at risk. Medication is not managed well. Accurate, complete and up to date records are not kept to demonstrate that medication is administered correctly and as intended by the prescriber. Medication is administered covertly to some residents without adequate safeguards in place to ensure this is in the context of existing legal and best practice frameworks. EVIDENCE: Five resident files were checked and all were found to include a copy of their care plan. Four of the five care plans had been developed following their arrival at the home, the fifth had not been fully developed until a month after Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 13 they had moved into the home. The nurse in charge stated that this was because the resident had originally come into the home as respite care from another Prime Life home. On further checking the paperwork it was noted that part of the care plan documentation had been devised by the home where the resident had previously lived and had not been reviewed on moving into the home. The suitability of this care plan was discussed with the acting manager, as certain information was not included. This included that the resident was vegetarian. The acting manager acknowledged this and stated that this would be addressed. It was noted that not all areas of the care plans checked had been reviewed on a monthly basis and not all documents had been signed or dated by the person completing them. It was also noted that some documents had not been completed correctly, which was a little confusing to the reader. On checking the care plan belonging to a resident with pressure sores it was noted that it included a wound plan for three pressure areas. On checking the regularity of dressing changes it was evident that two areas had been recently checked and redressed though there was no evidence to suggest that the third had been checked or redressed since 26th September 2007. On speaking with the nurse in charge no reason for this could be given. On discussion with care workers on duty on the day of the site visit it was reported that a deterioration had occurred on one of the residents heals, this information had been shared with the nurse in charge previously who applied a cushion protector to the heal. No further action had been taken even though the carers stated that further deterioration had occurred and no record of the deterioration or action taken could be found. The acting manager acknowledged this shortfall and has recently developed a weekly wound dressing and care plan audit document, which the registered nurses have recently started to use to keep abreast of the pressure area care within the home. Risk assessments addressing the resident’s specific health and welfare needs were in place. These included nutritional risk assessments, tissue viability risk assessments, mobility risk assessments and risk assessments for aggression and abusive behaviour and choking. It was noted again that not all areas of the risk assessment documentation had been reviewed on a monthly basis and not all documents had been signed or dated by the person completing them. For two residents staff had been advised by the dietician to monitor their weight every two weeks, on checking the paperwork held, one had been weighed monthly whilst the second hadn’t been weighed for two months. It was also noted that a tissue viability risk assessment had not been reviewed since the 14th August 2007. On speaking with the acting manager it was evident that she was aware of this problem and had recently devised a care Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 14 plan audit form, which will enable her to assess all the current care plan documentation and address any shortfalls. Fluid balance charts and turn charts were in use for a number of the residents, it was noted that some were more thorough than others, and for one resident it was noted that the day prior to the site visit these had not been completed. The care worker acknowledged this and explained that this was down to running out of time. On checking the resident’s files it was evident that health care professionals were being involved in their care. These included the local GP, Dietician, community nurses, opticians, and psychiatrist. The resident’s chiropodist also visited on the day of the site visit. All residents and/or their relatives spoken with stated that overall their current care needs were being met and that they were treated with respect and cared for in a dignified manner. Comments received included: “They try to treat the residents as individuals”. “The carers are pretty good on the whole, they are just about meeting my needs”. “I feel they are meeting his needs [relative], they all seem very nice [the staff] and they all know who he is”. The CSCI Pharmacist Inspector found evidence that the standard of medication management varies in the different units. Medication policies and procedures are in place however staff are not always following them correctly particularly in relation to administration, records and storage. There are detailed protocols to inform nursing staff how ‘when required’ medicines should be administered. However other medication records including admission details, risk assessments and care plans are not always completed fully or adequately. Medication is administered disguised in food or drink to some residents who may otherwise refuse them without all the necessary records for consent and covert administration being completed correctly and fully. A consent form was seen that had been signed by a relative and the GP that stated that a risk assessment has been completed by staff in the home and that the resident needed the medication covertly, however no written risk assessment could be found by the nurse in charge. A medication that should not be crushed was being given crushed and a second nurse could not explain how medicines were Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 15 given when they were administered in this way. There was no evidence that the advice of a pharmacist had been sought to confirm that no alternative liquid medicine was available and that the individual medicine could be crushed or given in food or drink. One resident had a drug allergy recorded in details within the personal file but the MAR stated ‘no known allergies’. Medication administration records (MAR) were not being followed carefully and signed correctly at the time when administration had been witnessed for individual residents. The majority of MAR for residents on Unit 1 for medicines given in the afternoon and evening of the previous day had not been signed although it appeared that they had been given. On the day of the visit the morning medicines that should have been given at 10 a.m. were at least two hours late on the downstairs units which meant that some doses would be given with too long or too short a gap resulting in the possibility of side effects or medicines not working correctly. It was also noted that the usual administration times meant that the intervals between doses on Units 1 and 2 were four hours in the day and 12 hours at night. An antibiotic medicine that needed to be given four times a day with regular intervals had been given with an excessively long gap between the night and morning dose. A medicine prescribed five times a day for five days had been given four times a day for eight days and another medication to be given weekly had been signed for as being given on three consecutive days two of which were then crossed through. One medication had been recorded as out of stock and not given for seven days. Most MAR were printed by the community pharmacy however some had been constructed using sticky labels which is against good practice recommendations from the Royal Pharmaceutical Society and where MAR were handwritten or amended they were not signed and dated. There was only one medication fridge per floor although there was a trolley in each unit. Fridge temperature records were not being taken regularly and one of the fridges had been excessively high three times within a month because it had been left turned off Two boxes of a very expensive injection that required fridge storage were kept in a cupboard. The nurse in charge of the unit was not aware that it should be stored in a fridge although the storage temperature was stated on the box. The nurse said that they had received training on how to administer it correctly and had given it regularly for some time. There was also medication that had been received at least two days previously that needed fridge storage but had been left in a box in a storage area with other medicines waiting to be checked in. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 16 Three immediate requirements were left in relation to medication and information was provided from the registered provider within 8 days detailing steps taken to address the concerns. This included: • Changes to the timing of medication rounds, more staff being available during administration rounds, and more regular supervision with random audits to check competencies. • Advice and support from the Community Pharmacist including a review of all residents who receive medication covertly to ensure that where no liquid alternative is available the medicine can be crushed. • Monthly reviews of medication administration by the Acting Manager and the Community Pharmacist. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and assisted to make choices on a daily basis. EVIDENCE: Choices are offered on a daily basis including what time to get up, what to wear, what time to go to bed and wether to join the other residents in the dining room for meals. Mealtimes are extremely flexible at Charnwood Lodge, breakfast is available from 9.30am to 11.30am, (though the homes services manager stated that breakfast is made available from 7.30am for those who want it earlier), lunch is available from 12.15pm to 2.00pm the evening meal is available from 3.30pm to 5.30pm and supper is provided from 7.00pm onwards. Snacks and drinks are also available throughout the day. A large choice of food is available at all meal times and diabetic, vegetarian, soft and liquidised diets are catered for. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 18 A study has recently been carried out into the eating habits of the residents living in homes owned by Prime Life Limited. The results of this study have been published, entitled ‘A Passion for Food’, it provides an insight into current practices with regard to food, meals and mealtimes and offers ideas for improving and developing a more flexible and suitable service for the individual residents. Residents and/or their relatives spoken with said that the food was good on the whole, there was always a choice and that they could take their meals in their room if they wished. Comments received included: “He gets lots of food and its always good, it’s really good to see him eating again and getting his weight back up”. “The food fluctuates, sometimes it can be really good, they do a beautiful chocolate cake”. Family and friends are strongly encouraged to visit and residents were seen receiving visitors throughout the site visit. All residents spoken with stated that their relatives and visitors could visit at any time and relatives spoken with during the visit confirmed that they were made welcome and were able to visit whenever they wished. There is a dedicated minibus available for use and trips out are provided on a regular basis. In house activities are offered by the homes services manager on an informal basis and care workers are responsible for doing small group activities or one-to-one activities such as reading the newspapers and doing jigsaws within each unit, though many of the care workers spoken with did state that they had little time to commit to these activities. During the site vist some residents enjoyed a session of flower arranging though it was noted that the majority of the residents didn’t join in and spent their time sitting with the other residents in the lounges. A visitor spoken with during the site vist did share that she would like to see more activities and stimulation offered to those living at the home. On checking the homes newsletter it was noted that a number of events have been arranged for the coming weeks including a bonfire party on 5th November, a remembrance gathering including a 3 course lunch on 11th November and a coffee and cake morning on 17th November. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to deal with complaints and to protect residents from potential harm. EVIDENCE: A complaints procedure is in place, a copy is given to all residents and/or their relatives before moving into the home and details of how to make a complaint and comment forms on which to record a complaint are available throughout the home. The acting manager stated that seven complaints have been received since the last inspection, one of which was received via the Commission for Social Care Inspection; this was confirmed on checking the complaints file. The complaints, which included concerns regarding the cleanliness of the toilets and the general care of a resident, were all investigated appropriately and where necessary actions taken to address the issues identified. All residents and/or their relatives spoken with were aware of whom to talk to if they were concerned about anything and all were confident that any issues raised would be dealt with appropriately. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 20 Comments received included: “I would talk to the manager, if they were busy I would try one of the seniors”. “I would talk to xxxxx [the acting manager] or xxxx [the administrator] I had to make a complaint once and she sorted it for me”. All staff working at the home have recently undertaken training in the protection of vulnerable adults and a leaflet has been provided to all staff which includes relevant information and guidance on protecting the residents in their care. The acting manager is aware of the procedures to follow to ensure that the residents in her care are protected and all care workers spoken with during the site visit were aware of the actions to take, should they suspect any form of abuse. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 21 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): 19,20,23,24,25,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of accommodation within the home is very good, providing the residents with an attractive and homely place to live. EVIDENCE: Charnwood Oaks is a purpose built care home providing accommodation for up to 84 Residents within four separate units. Each unit offers a lounge area with a small kitchen area where snacks and drinks can be prepared and assisted bathing facilities are provided. The main dining room can be found on the first floor and residents were seen accessing this facility throughout the site visit. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 22 The home is extremely well maintained both internally and externally. The decoration and furnishings throughout the home are both of a high standard and are presented in a comfortable and homely way. All rooms are single with ensuite facilities, which include a toilet and shower area. The rooms belonging to four residents were seen during the visit. All were clean, appropriately furnished and included their own personal belongings. All areas of the home seen on this occasion were clean and fresh. There is an attractive secure garden area accessible from the downstairs lounge areas for residents and visitors to enjoy and ample parking is available at the front and side of the home. All residents and/or their relatives spoken with were satisfied with the accommodation provided however, one relative did explain that the main dining area got particularly hot in the height of summer. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 23 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained and competent to do their jobs however, the acting manager must monitor staffing levels to ensure that enough staff are on duty to meet the ever changing needs of the residents. EVIDENCE: Staffing levels were checked during the visit. Currently staffing levels allow for three or four care workers on each unit during the day. There is one registered nurse rotered on to cover unit one and two throughout the day and a registered nurse is rotered on to cover units three and four in the afternoon with a second registered nurse to cover unit four in the morning. Throughout the site visit it was evident that this was not sufficient. The acting manager stated that a care worker should be on duty at all times in the lounge areas to assist with the residents and their needs. On a number of occasions throughout the day the lounges were left unattended for some time and the residents were left too there own devices. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 24 Due to the registered nurse on the ground floor being responsible for both units, medication was not being administered at the correct time on unit two, with the residents having to wait over two hours for their morning medication. This occurred on both days of the site visit. On speaking with the nurse on duty we were informed that this happened on a regular basis. This was discussed with the acting manager and Prime Life’s director for elderly services who acknowledged this and agreed that this was unacceptable. We were informed that a meeting had already been arranged for the Wednesday following this site visit to review current staffing levels. All of the residents and/or their relatives spoken with during the site visit felt that, overall, their current care needs were being met and on speaking with five care workers on duty during the visit it was evident that they were well aware of the individual needs of the residents in their care. Three staff files were checked and were found to include all the necessary checks including references and a CRB (Criminal Records Bureau) check. The acting manager explained that all new care workers complete a period of induction and a staff handbook, which includes relevant policies and procedures, is given to all staff employed. This was confirmed on speaking with five care workers and the homes services manager. A number of training courses have been provided since the last inspection including: Moving and Handling Food Hygiene Fire safety First Aid Hoist training COSHH Protection of Vulnerable Adults Dementia Awareness training is booked for 3rd December and the acting manager stated that she was currently looking into arranging NAPPI (Non abusive psychological and physical intervention) training for all the care workers. Information received during the site visit showed that fourteen staff members have completed an NVQ (national Vocational Qualification) level two or above. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 25 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): 31,32,33,35,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the management approach within the home. Their health and welfare are promoted and protected, though further improvements on risk assessments would ensure their ongoing safety. EVIDENCE: The acting manager has a number of years experience in care and is currently going through the process to become the registered manager of Charnwood Oaks with the Commission for Social Care Inspection. She is currently completing her NVQ level 4 and is registered to commence her Registered Managers Award. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 26 All residents and visitors spoken with during the visit stated that the acting manager was approachable and would have no hesitation to talk to her should they need to. Care workers spoken with felt supported by the acting manager and all spoken with stated that she was always available to talk to should they need to discuss any issue or concern. One care worker explained: “Any problems you can go to xxx [the acting manager] or xxx [Prime life’s Director of Elderly Services, there is always someone you can go to, if there not there when you ring they will always ring you back”. The acting manager stated that staff meetings are provided, though it was acknowledged that there hadn’t been one for sometime. Minutes of the last staff meeting held on 12th April were seen and on speaking with five care workers we were informed that staff meetings had been held, though not as often as some would like. The acting manager explained that two care workers had recently been promoted to the role of care coordinator and part of this role would be to organise and deliver regular staff meetings. This was confirmed on speaking to one of the newly appointed care coordinators. On speaking with a relative visiting during the site visit we were informed that relative meetings are offered throughout the year, minutes of the last meeting held on 23rd May 2007 were seen. The relative did share that although the opportunity to discuss any issues are available, follow up of issues raised was not always forthcoming. The acting manager explained that it was her intention to commence ‘monthly surgeries’ as well as the regular gatherings to enable relatives to have the opportunity to talk on a one to one basis about any concerns they may have. Appropriate records for the safe keeping of resident’s money are in place, receipts are given and signatures are obtained for any transaction carried out on the resident’s behalf to ensure that their finances are safeguarded. Training in Health and safety is provided to all staff during their induction period and training in fire safety, food hygiene, first aid and moving and handling are provided on a regular basis. One of the residents case tracked had bed rails in place, on checking the paperwork it was noted that although a risk assessment was in place and consent had been received for the use of these, there was no evidence to suggest that their use was being reviewed on a regular basis or that regular checks of the equipment are being carried out. Kitchen facilities, including kettles are provided in all the lounge areas throughout the home. On speaking with the acting manager it was evident that risk assessments had not been carried out to ensure that this was a safe practice. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 27 Whilst we were told that a member of staff should be in the lounge areas at all times there were many times during the site visit when this wasn’t the case. This presents the possibility of residents accessing a kettle of boiling water. The acting manager stated that a risk assessment would be completed. A monthly newsletter is developed and distributed throughout the home. Policies and procedures required for the safeguarding of residents are in place. A quality assurance audit is carried out on an annual basis with the last audit taking place on 20th November 2006. A copy of the results of the audit was sent to the CSCI for information and copies are available at the home for anyone to access. Not all records seen on this occasion were up to date or accurate, the acting manager acknowledged this and steps are being taken to address this shortfall. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 28 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 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 N/A 18 3 4 4 X X 4 X 4 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 2 3 Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2)(b) Requirement The registered person shall: Keep the service users plan under review. The registered person must ensure that the residents care plans and associated documents are kept up to date and accurate. Care workers need to have up to date information to enable them to care properly for the residents. The registered person shall ensure that: Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person must ensure that the risk assessment documentation is up to date and accurate and that it contains all the risks presented to both the resident and the staff. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 30 Timescale for action 07/11/07 2 OP8 13(4)(C) 07/11/07 3 OP9 13 (2) Care workers need to be aware of all the current risks to the residents and the actions to take to minimise those risks. Accurate complete and up to date records must be kept of all medication administered to service users to ensure that medication is administered safely, correctly and as prescribed. Medication must be administered according to the prescriber’s instructions to ensure that it is given correctly and safely to manage individual health needs. Medication must only be administered covertly and/or in food or drink within the context of existing legal and best practice frameworks to protect the person receiving the medicines and the care workers involved in giving the medicines. All medication must be stored within the temperature range recommended by the manufacturer to ensure that medication is not used when it has become deteriorated or contaminated. The registered person shall, having regard to the size of the home, the statement of purpose and the number and needs of service users – Ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health 22/10/07 4 OP9 13 (2) 22/10/07 5 OP9 13 (2) 22/10/07 6 OP9 13 (2) 03/12/07 7 OP27 18(1)(a) 03/11/07 Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 31 and welfare of service users. Staff must be given the time to provide the necessary care and support to meet the needs of the residents living in the home. The registered person shall ensure that – All parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person must ensure that risk assessments are carried out all safe working practices. Residents living in the home need to be protected from any possible harm. 8 OP38 13(4)(a) (c) 03/11/07 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. Refer to Standard OP9 Good Practice Recommendations The registered provider should review medication administration records, policy and procedures so that sticky labels are not used on records and handwritten records are signed, dated and witnessed where possible to ensure that records are accurate, complete up to date and meet good practice recommendations. The registered person should review fridge storage arrangements to ensure they are adequate to meet the needs of all units and that temperatures are monitored DS0000066624.V348381.R01.S.doc Version 5.2 Page 32 2. OP9 Charnwood Oaks 3. OP9 4. OP12 regularly so that medicines are kept within an appropriate temperature range. The registered person should review the process for medication administration to ensure that medication administration times are flexible and suitable for all prescribed medication and that nursing staff are able to undertake the task in a timely and appropriate manner without excessive interruption. The registered provider should ensure that whenever possible activities are accessible to more residents on a more regular basis. Charnwood Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Oaks DS0000066624.V348381.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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