Inspection on 12/09/07 for Charter House

This inspection was carried out on 12th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charter House 10/09/08

Charter House 17/08/06

Charter House 17/05/06

Charter House 15/02/06

Charter House 21/10/05

Charter House 15/11/04

Charter House 06/04/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Charter House 15 Queens Road Donnington Telford Shropshire TF2 8DB Lead Inspector Deborah Sharman Key Unannounced Inspection 12th September 2007 09:15 Charter House DS0000020543.V343555.R01.S.doc Version 5.2 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 Charter House DS0000020543.V343555.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 Adults 18-65. 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. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charter House Address 15 Queens Road Donnington Telford Shropshire TF2 8DB 01952 676865 F/P 01952 676865 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) Mrs Sukjit Kaur Kang Mrs Sukjit Kaur Kang Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Brief Description of the Service: Charter House is a care home providing accommodation and personal care for up to eight people with difficulties with mental health. It is privately owned and is a detached property situated in a residential estate in Donnington, Telford. All bedrooms are single occupancy none of which have an en suite facility. The communal areas are homely and domestic in character. The property is undergoing a refurbishment and redecoration programme. Weekly fees range from £280.00 - £ 385.00 Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this unannounced key inspection between 9.15 am and 5.00 pm. As the inspection visit was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’. These are the National Standards, which significantly affect the experiences of care for people living at the home. Progress the home has made towards meeting previous CSCI requirements issued to ensure improvement at the last key (August 2006) and random (February 2007) inspections was also assessed. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home in their annual return. Additionally prior to inspection, we sought the views of people living at the home and those of their relatives and other professionals associated with the home. Written responses were received from two relatives, four Local Authority Care Managers and three health professionals. Seven people who live at Charter House returned questionnaires about their experience of living at the home. All this information was analysed prior to inspection and helped to formulate a plan for the inspection and has helped in determining a judgement about the quality of care the home provides. During the course of the inspection the Inspector used a variety of methods to make a judgement about how service users are cared for. The Registered Manager was not available but the Deputy Manager was throughout the inspection day to answer questions and generally support the process. The Inspector interviewed a senior care staff member as she was the only staff member on duty, had the opportunity to talk to a new resident in some detail upon arrival, spoke to another resident for some time at the top of the stairs at the end of the day and chatted briefly to 3 residents in their bedrooms as part of the tour of the environment. The Inspector assessed in detail the care provided to a new resident and two others using care documentation and sampled a variety of other documentation related to the management of the care home such as training, staff supervision, maintenance of the premises, accidents and complaints. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Not all residents are happy with their day activity. The home is recognising the need to develop greater opportunities and this is currently under review. One resident would very much like to attend football matches and is not presented with the opportunity frequently enough. Cost, transport and inflexible staffing level arrangements conspire to make this difficult but it is possible with sufficient commitment and planning. Care plans must be adhered to at all times. There is evidence that a behaviour plan has not been adhered to. There is no clear evidence whether this was an Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 7 isolated incident or not. Non-adherence to a behaviour care plan has compromised the rights of the resident and had the potential to put both the resident and staff member at risk. However all staff have very recently undertaken managing behaviour training and it is hoped that this in addition to an investigation promised by the Deputy Manager will seek to standardise performance which is evidenced elsewhere as good on the whole. Progress towards improving the environment is slow. Some improvements have been made but the finish is not to a high standard and many areas of the communal areas require upgrading especially the kitchen, bathrooms and garden areas to provide more pleasant living facilities that comply with modern expectations. Following an adult protection investigation early in 2007 some steps have been taken to improve record keeping systems in respect of the management of service users monies. Sufficient safeguards however are still not in place, pooled cash in hand held did not tally with records and explanations given to account for why the money was missing were unacceptable. Residents’ financial interests are not being fully protected and their rights, wishes and vulnerabilities have not been considered. Lessons have not been learned from what was for the provider a difficult time during earlier investigations. The findings from this inspection about how service users monies have been managed have been passed to Social Services for their consideration. A requirement to review the current management arrangements for the home has not been met. Due to ongoing absence the Registered Manager who is also the Registered Provider is not sufficiently in day-to-day charge of the home and is not meeting her regulatory duties. In spite of this there are many good outcomes for residents. However there are some failings in management accountability which are directly impacting upon service users, such as how their financial interests are being protected, and these require attention without delay. 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. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4. Quality in this outcome area is good. A resident who has recently moved in was satisfied that s/he had sufficient information available to help with the decision to move in. Steps are taken to assure residents before they move in that their needs are known and can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector spoke to someone who had very recently moved into Charter House. He said he was settling well describing the experience as ‘grand’ and ‘like starting a new life’. He was satisfied that he had had sufficient information about the home prior to moving in and a trial visit there helped his decision to move in. Prior to inspection a local authority care manager confirmed in writing to CSCI that the home ‘has done a thorough assessment of my client prior to admission’. A staff member also felt that staff had been furnished with sufficient information to help them to meet his needs from the point of admission. All supporting documentation was available to demonstrate that sufficient care had been taken to assure that the home could meet his assessed needs prior to offering a place. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. Staff are aware of residents needs. Most significant needs and risks are identified and are recorded in individual peoples’ care plans providing guidance for staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans and risk assessments for needs and risks pertinent to the new resident are in the process of being developed. Some care guidance was in place but some areas of significant need and risk had not yet been developed. Staff were aware of this but were unconcerned as the needs were not currently impacting on the person and staff were keen to complete the care planning in conjunction with him at his pace whilst allowing time for him to settle in. There was no concern that this lack of documentation was affecting outcomes for this person and sufficient information was available to compensate for this if need be in pre admission information collated. A risk assessment in respect Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 11 of the self-administration of medication must however be completed without delay. Care plans for more established residents are good and contains sufficient information about their range of individual needs which staff were familiar with in discussion. It is positive to see peoples diverse spiritual needs acknowledged and respected within the care planning process. Attention must be paid to ensuring that care plans are adhered to. For example one care plan guides staff to manage a resident’s behaviour through diversion and diffusion tactics offering positive reinforcement through praise where possible. Discussion with this resident showed that on the one occasion discussed the care plan had not been adhered to. This gives rise to concern but is explored more fully under Standards 22 and 23 ‘Complaints and Protection’. Feedback to CSCI from people living at Charter House indicates that they are generally satisfied with how they make choices about their lives with the exception of choices available to them about what they do each day. The staff are aware of these dissatisfactions and are looking to provide a greater range of opportunities from within community resources. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. A range of activities is available and is under review following feedback from some residents expressing dissatisfaction with current day arrangements. Residents’ religious needs are respected and their diverse beliefs are encouraged and supported. There is room to provide improved opportunities in some areas to meet individuals’ interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some residents are becoming fed up with their day opportunities and the home is engaging with community resources to develop the range of opportunities available. One resident has joined a community gardening project in accordance with his expressed wish and to date is motivated and keen to continue with this. Another resident who is a talented artist, at the time of inspection was looking forward to joining a community class the following week. Residents enjoy autonomy where they access community resources independently and records show residents enjoying a range of Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 13 activities both at organised community facilities, independently and in house. Referrals have been made to Social Workers the Inspector was told for two residents who have expressed an interest in taking up paid and voluntary work. Four residents are looking forward to a holiday in October 2007 funded by Charter House. The other four have chosen not to go. One resident has felt isolated on the basis of gender. Following the new admission to the home he now has male company. It is however difficult for him to engage in his passion – supporting the local football team - on the basis the Inspector was told of ticket cost and transport. Staff time with and support for service users outside the home at evenings and weekends is compromised given that staff work alone. This should be included in the plan of care with steps in place to enable this to happen for the resident. Staff spoken to had a good working knowledge of one resident’s commitments to her church. She is occupied several times per week in this outside the home but also is able to undertake bible study on the premises with a friend who visits. Feedback from questionnaires distributed to residents by Charter House show a high level of satisfaction with how their religious and cultural needs are respected and met. Food records are showing that meals provision has improved since the last CSCI inspection visit. Residents are now having a hot meal daily and a resident confirmed this. Alternatives to the menu are still not being evidenced. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good overall. People living at Charter House are supported to obtain medical assessment and care when their health needs change. Robust health records show that the continuity of this care is good and promotes the health and well being of residents. Some action is required to identify and minimise any risks when residents take responsibility for administering medications independently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents living at Charter House have mental Health needs. There is good evidence that their well-being is reviewed regularly with psychiatrists who have a good working relationship with the staff at the home. Health records are excellent and provide good evidence that residents’ changing health needs are recognised and responded to. It is a challenge for residential care staff where working patterns are varied to provide continuity of care. Health records show that Charter House is providing good continuity of care by following through medical advice, facilitating health tests and then Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 15 seeking and recording the outcome of the tests carried out. This was also evident in the provision of routine health screening. It was clear for example that dental and optical screening had resulted in positive outcomes for one resident who as a result obtained new dentures and new glasses, maximising health, dignity and independence. The home has also developed a continence policy since the last inspection, which the Inspector has advised, needs to be reviewed and authorised by a medic or continence nurse. Care plans contain guidance for residents who have continence needs and these were viewed in respect of two residents. Visits to the bedrooms of these two residents shows continence management to be more successful in respect of one resident than the other. A strong odour in one bedroom indicates that continence management arrangements require review for this resident to promote independence and dignity and an improvement to his / her personal living environment. Medications are generally well managed. Storage is safe, there are no controlled drugs and staff are all appropriately trained. Care plans contain good information about the medications that residents are taking. Medications are checked onto the premises when delivered and are recorded out when removed safely from the premises assuring a safe and accountable system. Some areas for improvement to medication have been identified. Steps have been taken to reduce risk for a resident who is self medicating. For example he is not provided with a months supply of medication issued by the dispensing chemist. Staff consider it safer to provide him with a weeks supply and are consequently double dispensing from the packaging dispensed by the pharmacist. This introduces the risk of staff error. Although preadmission assessments indicate the resident has self-medicated successfully for many years, a formal risk assessment of the resident’s ability to self-administer and the control measures required has not been formally considered. This needs to be carried out without delay. How staff are checking compliance with self administration also needs to be considered as part of the risk assessment with any audits recorded. Assessment of medication stocks showed an inhaler to be amongst the medications for this same person with his name handwritten on the box. There was no evidence that this had been prescribed and this needs to be verified with a GP. Criteria for its use must be obtained which should also be considered as part of the risk assessment. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate on balance. Two adult protection investigations are now closed and some improvements have been made as a result. However this inspection shows the issues have not been fully learned from and residents are not fully protected. Residents’ monies are being used inappropriately and insufficient safeguards remain. Additionally whilst behaviour management is largely good, there is evidence of some covert behaviour management, which is not in line with recognised good practice, or agreed plans of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Deputy manager reported that there have been no staff disciplinary actions, no restraints, no behaviour incidents in 2007 and only two minor accidents in the last 12 months. He said that all staff have done adult protection training (one who hadn’t at the last inspection has resigned) and that all staff have recently undertaken distance learning training in managing challenging behaviour. A staff member confirmed having done this training and reported it as having been valuable. There have been 2 complaints since the last key inspection. Both these complaints were made to Social Services, applied to one resident and were both subject to adult protection investigations. The allegations were in respect of health and financial management and both matters have been investigated Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 17 and closed by the Local Authority. The home worked cooperatively with the agencies during the investigation. Financial records are now better maintained. Two staff and the resident are signing for financial activity in individualised records and a description of the activity is recorded to justify the expenditure. There is a running total therefore of what monies residents should have at any one time and the deputy manager is checking the accounts regularly. However residents’ monies are pooled, are not accessible to staff and are therefore not checked daily by staff. Only the managers have access to this pool of money, which at the time of inspection did not balance. The Inspector was told that it did not balance because for convenience it is used to buy things and used to subsidise residents and staff wages. This financial activity is not recorded, not accounted for, not known to residents and not authorised by residents. It is unacceptable. As a result of this inspection, the Inspector has notified Social Services of findings in respect of how services users monies are being managed and they are considering their response. The Deputy Manager has not written to CSCI to confirm any remedial actions taken as promised. Incident records for 2005 and 2006 for more than one resident show a consistent staff approach to behaviour based upon diversion, diffusion, praise and reassurance in line with plans of care. There are no behaviour incidents recorded for 2007 and staff and the Deputy manager confirmed there had been none and that incidents have been decreasing. A medical practitioner has said ‘they have taken some very difficult patients and worked well with them’. It was concerning therefore to hear a resident asking for the return of possessions that he said had been taken from him by staff when he was ‘behaving badly’. This intervention is not in accordance with his plan of care, does not comply with good practice and is unlikely to diffuse but rather to heighten escalating patterns of behaviour. This indicates that either record keeping does not accurately reflect incidents within the home or that if records are accurate, that this person’s possessions were removed and not returned prior to 2007. The Deputy Manager undertook to investigate and act upon this. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is adequate. The home is comfortable and people living at the home like their bedrooms. There has been some improvement since the last key inspection but progress is slow. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some improvements to the environment have been made since the last key inspection. Some communal areas have been redecorated, the utility area has been refitted and appropriate hand wash facilities are available to minimise the risk of infection control. Residents like their bedrooms but incontinence management needs to be reviewed in some cases to eliminate unpleasant odours and infection risk. New bathroom suites have also been fitted but this seeks to further emphasise now the need to finish the bathrooms to the same standard as the new suites are at odds with the poor quality flooring and scuffed wooden wall panelling. The plans to refit the kitchen have also not Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 19 been realised but it was found to be clean and well stocked. Kitchen appliances are also kept clean. The Inspector looked at the garden. Much of the grass has gone to weed and there is no colour. The Deputy Manager who is managing the service in the absence of the Manager and covering care shifts often without a break is also responsible for garden maintenance. Understandably it has not been a priority but the garden is untended and does not provide pleasant additional space for residents to enjoy. The Deputy Manager confirmed that residents do not spend much time in the garden. One resident said he is looking forward to gardening in the spring. Doors were not wedged open at this inspection and a Fire Officer Visit in March 2007 concluded that the home fully complies with fire safety. The Deputy Manager confirmed that action has been taken to improve the hot water supply to the home to ensure that there is sufficient hot water for all residents at times of high demand. He confirmed the provision of a new water tank and resolved to supply CSCI with a copy of the bill as evidence. At the time of writing this has not been received. A staff member spoken to said that the environment meets all residents needs. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35. Quality in this outcome area is good. Staff are adequately trained and supported to support people at the home. Staff are respected by people living at the home and by visiting professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from a range of sources about the quality of staffing is good. CSCI was told: ‘X, Y and Z was acted upon immediately when brought to staff attention’ ‘Secure, safe, friendly, caring, staff keen to address needs, residents feel listened to and respected, promotes stability.’ ‘Keeps me informed of any changes regarding my clients and liaises with all who are involved in their clients care. ‘Fully trained staff’ Very pleasant and cheerful staff.’ Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 21 Staff seem to be helpful and caring. ‘When my relative first went into the home she was severely mentally ill but with the support of the manager and staff she has greatly overcome the issues that were affecting her’. I am happy in this home. I would not manage on my own. The staff do a very good job. Records and discussion with staff show that the provision of training and formal supervision is good. Staff have undertaken all expected training including training very recently in managing challenging behaviour and the newly introduced Mental Capacity Act. The provision of supervision for two staff sampled also meets the national minimum standard in terms of content and frequency. Staff report being fully supported and yet corrected when required and supervision records evidence this. Supervision records must be held separately for individual staff. Currently records for all staff are held in one bound book, which does not protect confidentiality for others, should a staff member wish to see their own records. Following feedback prior to inspection, staff and the deputy manager agreed that the team would benefit from receiving training about one resident’s recently diagnosed condition. At the time of inspection there was one staff vacancy, which amongst a small team is a sizable reduction in the percentage of the team. This combined with the holiday period was proving a challenge to find staff cover as there is no contingency system for absence. Discussion with the Deputy Manager indicated that consideration would be given to employing bank staff to use in times of shortage as perusal of the rota showed that in August the Deputy Manager worked nineteen days consecutively without a break. This is not safe practice. Activities required by individual residents can be compromised by lone working arrangements. This needs to be addressed to ensure that residents can pursue interests that may differ from the majority. No staff have been recruited since the last key inspection and therefore recruitment procedures were not assessed on this occasion. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate overall although performance is very mixed. Day to day outcomes for people living at the home are good and feedback is positive. However there are some repeated fundamental concerns about the management of the home. The Registered manager through absence is not able to discharge her responsibilities and the home is not always managed in the interests of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been no change in the management arrangements for the home since the last inspection and this is unsatisfactory. The Registered Manager, due to absence, although responsible for the home is no longer effectively in Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 23 day-to-day charge. At the last inspection there was no evidence of her attendance or input to the home and seven months later discussion, assessment of rotas and other documentation throughout the inspection day shows that the situation remains the same. This inspection has shown that there are many good outcomes for residents but that there are also some concerns about how the home is managed and a decision in writing to CSCI about plans for the future management of the home is required without delay. The Deputy Manager promised this on behalf of the home by 14 September 2007 and at the time of writing this has not been received by CSCI. Minutes show there have been three staff meetings in the last 12 months and recently that weekly residents meetings have been introduced. CSCI has received positive feedback from a third party partner about the introduction of these meetings along with the advice that they should continue. There is some indication that residents may be finding them too regular and the Deputy Manager indicated that the frequency is under review. The homes quality assurance system is a work in progress. Since last time service user feedback has been analyzed and shows high degrees of satisfaction but no tool is yet available to respond to the outcomes of the feedback given. Nothing is available either to support the homes assessment of its own performance across the range of performance indicators. The Deputy Manager accepted the need for the further development of the system. Service and maintenance certification was assessed: Fire safety was not assessed in detail as the home had received a satisfactory report from a Fire Service Inspection in March 2007. The Deputy Manager said that a new water tank has been provided to ensure that hot water is available to all residents during peak periods. Omissions were found in water temperature monitoring and practice does not fully comply with control measures indicated in a recently reviewed risk assessment where residents are described as ‘vulnerable’ to scalding. No systems have been or are in place to assess the risk of or to minimise risk to residents and staff from legionella. An electrical safety certificate was not available to indicate that wiring within the premises has been tested and is safe and the Deputy Manager could not recall one having been undertaken in the past. COSHH assessments are in place using information from data supplied by the manufacturer. However COSHH assessments could not be located for two products randomly sampled from the COSHH cupboard where they were safely being stored. COSHH assessments should be reviewed to ensure they accurately represent how risks are minimised for all hazardous chemicals retained on the premises. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 24 Some fridge temperatures on occasions were recorded as exceeding the safe range and staff had not indicated that they had responded to this to minimise the risk of food borne illness resulting from inappropriate cold storage. General risk assessments are in place in respect of the premises and a contingency plan is in place should residents need to evacuate the premises temporarily. All staff apart from the Registered Manager have appointed persons first aid training. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 2 X Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation 1. YA17 16(2)(i) 16(4) 17(2)S4 Requirement The Registered person must ensure that records of the food provided for service users are in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. New requirements arising from random inspection 12.2.07. Not met at Inspection September 12 2007. Timescale for action 31/10/07 2 YA20 13(2) Steps must be taken to assess and minimise any risks posed by the self-administration of medication. This will enable residents to maintain their independence safely. New Requirement arising from this inspection September 2007. 30/09/07 3 YA23 20(1) Service users personal monies must not be paid into a bank account unless – 31/12/07 Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 27 a. The account is in the name of the service user/s to which the money belongs. b. The account is not used by the registered person in connection with the carrying on or the management of the care home. This will assure service users that their monies are better accounted for. New Requirement arising from this inspection September 2007. 4 YA23 13(6) Arrangements must be made by training staff or by other measures to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. New Requirement arising from this inspection September 2007. 30/09/07 5. YA24 23(2(b)(d) The proposed 31/03/08 refurbishment/redecoration/recarpeting plan must be completed. Date for compliance was 31/8/06. Second date for compliance was 31.8.07 Not met at September 2007. 6. YA24 23(2)(J) The Registered person must review the hot water supply to ensure that there is a sufficient supply of hot water to showers and all water outlets to meet the needs and preferences of all service users. Requirement arising from random 31/10/07 Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 28 inspection 12.2.07 Target date set for 31.3.07 and not evidenced at September 2007. 7 YA24 16(j)(k) Steps must be taken to maintain satisfactory standards of hygiene and keep all areas of the care home including bedrooms free from offensive odours. This will minimise the risk of cross infection for service users, promote their dignity and will provide a more pleasant living environment. New Requirement arising from this inspection September 2007. 31/10/07 8. YA37 9 The Registered person must review the current Management arrangements for the home. Requirement arising from random inspection 12.2.07 with target date of 31.3.07 and not met at September 2007. 30/09/07 9. YA39 24(1) The home must develop and maintain an effective quality assurance and monitoring system. This requirement is part met at inspection 12.2.07. Target date set for 31.5.07 and at September 2007 remains part met. 31/12/07 10. YA41 37 The Registered person must give notice to CSCI without delay of the occurrence of any incident as defined in Regulation 37 1(a) to 1(g) and any notification given orally must be confirmed in writing. New requirement arising from random inspection 12.2.07. 13/09/07 Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 29 No notifiable incidents by September 2007. 11 YA42 13(4) New Requirement arising from this inspection September 2007. Steps must be taken to reduce the risk to service users from scalds. 30/09/07 12 YA42 23 (2)(b) Steps must be taken to assure that the premises are kept in a good state of repair and that risks from electrical wiring and water quality are assessed by somebody competent to do so and are responded to where necessary. New Requirement arising from this inspection September 2007. 31/10/07 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 YA14 Good Practice Recommendations All service users should be supported to pursue their own interests and hobbies. Plans should be in place for example to support attendance at football matches through effective budgeting and the flexible provision of staff. New recommendation arising from this inspection September 2007. 2 YA20 Advice should be sought from the dispensing pharmacist about the practice of double dispensing. New recommendation arising from this inspection September 2007. 3 4 YA28 YA33 External grounds should be appropriately maintained. New recommendation arising from this inspection September 2007. Consideration should be given to suitable contingency arrangements to ensure that staff can be flexibly provided in the event of holidays, sick absence or following the DS0000020543.V343555.R01.S.doc Version 5.2 Page 30 Charter House resignation of staff. New recommendation arising from this inspection September 2007. 5. YA40 The Registered person should consider developing a policy to guide staff on the management of continence. This should be based upon agreed current up to date good practice. Recommendation arising from random inspection 12.2.07 Completed at Inspection September 2007. Advised review by incontinence nurse. Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Charter House DS0000020543.V343555.R01.S.doc Version 5.2 Page 32 - 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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