Inspection on 15/02/06 for Charter House

This inspection was carried out on 15th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 8 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 12/09/07

Charter House 17/08/06

Charter House 17/05/06

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 Keith Salmon Unannounced Inspection 15th February 2006 10:45 Charter House DS0000020543.V275888.R01.S.doc Version 5.1 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.V275888.R01.S.doc Version 5.1 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.V275888.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Charter House Address 15 Queens Road Donnington Telford Shropshire TF2 8DB 01952 676865 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. Sukhjit Kaur Kang Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2005 Brief Description of the Service: Charter House care home is a detached property situated in a residential estate in Donnington, Telford. Opened approximately 13 years ago it was further extended 5 years ago to provide accommodation and personal care for up-to eight adults with mental health care needs. The Registered Provider is Mrs S Kang, who is also the Registered Manager. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection commenced at 13.15 lasted 3.0 hours, and was undertaken by one Inspector. This Report is a product of observations made during a tour of the Home, which covered any progress made on a number of issues relating to standards of décor and furnishings, a review of progress in relation to ‘Requirements’ cited at the previous Inspection, perusal of documentation relating to care planning, medicines administration, staff training and supervision and staff recruitment/deployment, plus a range of documents/records reflecting the general operation of the Home. The Inspector also held discussions with the Owners (Mr and Mrs. Kang), the Senior Carer on duty (Mrs. Chris Turner) and two Residents. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 6 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.V275888.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These Standards were not assessed at this Inspection. EVIDENCE: Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9,10. Individual Care Plans are based on regular assessment of Resident’s personal goals. Residents, as far as their individual capabilities permit, are involved in determining all aspects of their life at Charter House. They are enabled, and supported, in conducting their lives at risk levels consistent with individual capability. Confidential information is stored and utilised appropriately. EVIDENCE: One of the Residents, present at the time of the Inspection, gave permission for the Inspector to view her file. This included:- a full pre-admission assessment carried out by suitably qualified staff, it was well-organised, clearly written, up-to-date and contained regularly reviewed care plans. A Requirement was made at the previous Inspection for strategies to be in place to develop the Home’s approach to ‘Risk Management’, i.e. to maximise opportunities for Residents to extend their safe involvement in society. Work undertaken in this respect has led the Inspector to consider this Requirement has been met. All confidential records are securely held in the locked main office. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17. Residents’ rights and responsibility are recognised and fully enabled. Residents are fully involved in the planning, and provision of a varied and healthy diet. EVIDENCE: Review of care records and discussion with Residents and Staff indicated Residents are both supported and enabled in determining there own lifestyle/activities. The menu was examined and showed a four-week cycle, which continues to evolve with input from individuals 1:1 discussions with Staff and through regularly held Residents’ meetings. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20. Residents’ care needs are identified and appropriate care provided. Storage, administration, reception and disposal of medicines are now in accordance with accepted good practice. EVIDENCE: Review of Residents’ Care Plans demonstrated evidence of input from visiting clinical professionals. Examination of medicine administration procedures showed Requirements cited at the previous Inspection, in particular with relation to the receipt and disposal of medicines, and the attachment of Resident’s photographs to Medicine Administration Record (MAR) Sheets have been met. A further ‘Requirement’ was that Staff must have access to accredited training in the administration of medicines. Although this has not yet been undertaken evidence was seen which showed 5 members of Staff have commenced a suitable course during January 2006 under the auspices of Telford and Wrekin Council. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Although Staff are aware of their role in the protection of Residents from abuse, neglect or self-harm Staff have yet to commence accredited training in prevention/management of verbal/physical aggression. EVIDENCE: Concern was expressed at the previous Inspection with regard to Home’s adult protection arrangements – specifically the need for greater detail in documentation of restraint and the need for reference in the Home’s ‘Abuse’ Policy to local adult protection procedures. Both of these Requirements have been met following revision of relevant documentation. Also, to further improve the Home’s performance in this important area, arrangements have been made to provide training in prevention/management of aggression through a 12-week course provided by Walford College. Six members of Staff will be undertaking this training. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,30. The continuing lack of investment, coupled with the lack of maintenance and effective cleaning regimes and other infection control practices, is placing Service Users at risk. Although the Home’s bedrooms, lounge/sitting and dining areas offer a homely ambience, the fabric and décor are looking extremely worn and some furnishings require urgent replacement. Residents have control of access to their bedrooms where deemed appropriate (e.g. possession of keys). However, furniture in bedrooms does not, in all instances, satisfactorily meet individual Residents’ lifestyle needs. Despite requirements relating to the downstairs shower having been addressed the shower room is not fit for its purpose. EVIDENCE: It is 5 years since the Home has benefited from any major refurbishment/ redecoration, which is evident from the generally worn appearance of fabric and furnishings. The Inspector was informed that redecoration proposals, previously brought to the attention of the CSCI, are ‘out to tender’ and work should commence during early spring of 2006 with completion within 6 months. The Inspector observed a chest of draws in a Resident’s bedroom was found to be collapsing and beyond repair. This appeared to be due to the kind of use to which the Resident had subjected this item, and the Inspector was advised that discussions were taking place between the Resident concerned, Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 13 the Home’s Management and representatives of Telford & Wrekin Social Services in order to explore the possibility of the Resident purchasing a more robust replacement from personal funds. A ‘Requirement from the previous Inspection was that the mattress in bedroom 4 was been replaced – this has been done. The state of repair of the ground floor shower has been partly addressed, i.e. repair of a leak. However, the window to the shower room is broken having recently been vandalised by an unknown assailant throwing a brick. The Inspector was informed this was to be replacement with a new double-glazed window. The Responsible Person must ensure the repair/replacement is completed by the ‘target’ date. COSHH products were appropriately stored with the relevant data sheets located alongside. Not all of the required areas had the necessary paper towels and liquid soap and the Inspector was informed this was to be addressed as part of the total refurbishment. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35. Numbers of Staff on duty appeared sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home in providing training for Care Staff, and to continuing supervision and support has improved. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staff numbers and skill-mix appear to enable a service provision, which meets the care needs of Service Users. However, a large proportion of ‘experienced staff’ cover is provided by the Registered Manager/Responsible Person – an amount of time in excess of that of a full-time post. In discussion the Manager and Deputy Manager explained the daily involvement of one or both of them, as Owners, as well as rostered Staff, did not impose a workload they considered to be onerous. This position will be reviewed again at the next Inspection. As the Responsible Person was present it was possible to examine Staff Employment Files. These demonstrated the Home is in full compliance with the Standard and Schedule 2 of the Regulations. Staff are subject to a thorough, and relevant, orientation/induction programme and supervision, with evidence of on-going training. However, there remains the need for Staff to complete the specialist training (e.g. prevention/ Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 15 management of aggression) which the Inspector was informed is to commence in the coming weeks. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,41,42. It was not possible to fully assess Standards 37 and 39 as there were only two Residents at Home throughout the visit, one of whom was not well enough to have discussion with the Inspector. A third Resident did return briefly and held a conversation with the Inspector before going out again. However, the impression gained from the discussions undertaken with Residents was they valued the general feeling of homeliness, and the support of Staff at Charter House. There has been some improvement in provision of staff training. EVIDENCE: Discussion with Staff, and review of staff records, showed that since the previous Inspection the Home has made some improvements in the provision of training for staff with good performance in relation to NVQs Levels 2 and 3. As stated above (Standards YA23 and YA35), there is still need for Staff to complete training specific to meeting the needs of the client group. Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 17 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X X X X X 3 2 X Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 18 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 1. YA20 Regulation 13-(2) Requirement All Staff responsible for administering medicines must complete training from an accredited external organisation which meets with the CSCI Standard. All Care Staff must complete accredited training in prevention/management of verbal/physical aggression. The proposed refurbishment/ redecoration/re-carpeting plan must be completed. The irreparable chest of draws in one Resident’s bedroom must be replaced. The broken shower room window must be repaired/replaced. Paper towels, liquid soap and bins for used paper towels must be provided in all required areas. The Registered Person must ensure, so far as is reasonably practicable, the health, safety and welfare of Service Users and Staff and ensure safe working practices to include mandatory training for all Staff. Timescale for action 30/04/06 2. YA23YA35 13-(6) 18- (1-c,i) YA24 YA26 YA27 YA30 YA42 23-(2-b,d) 23-(2-m) 23-(2)(b) 13- (3) 16(2-j,k) 12-(1-a) 13(4-a,c) 31/07/06 3. 4. 5. 7. 8. 31/07/06 31/03/06 31/03/06 31/03/06 31/07/06 Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Charter House DS0000020543.V275888.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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