Inspection on 17/08/06 for Charter House

This inspection was carried out on 17th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. 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 17/05/06

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 Joy Hoelzel Key Unannounced Inspection 17th August 2006 11:00 Charter House DS0000020543.V306695.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.V306695.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.V306695.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 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.V306695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2006 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. Weekly fees range from £270.16 - £ 511.72. 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. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over three hours on Thursday 17th August 2006. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty three of the forty three National Minimum Standards for Care Homes for Adults (18-65) were inspected on this occasion. Eight people are resident at the home. Three people were at the home; the remainder had gone out for the day to the Cotswolds. The deputy manager was on the premises supported by care staff. A tour of the premises took place, two resident care files was randomly selected and examined in depth, together with supporting documents and discussions were held with residents, staff and the deputy manager. What the service does well: What has improved since the last inspection? What they could do better: The programme for the refurbishment and redecoration of the premises must be within the agreed timescales. Arrangements must be made to reduce the risk of cross infection. The statement of purpose and service user guide must be available and in s suitable format. To reduce the risk of fire wooden wedges must not be used to prop open doors. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 6 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.V306695.R01.S.doc Version 5.2 Page 7 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.V306695.R01.S.doc Version 5.2 Page 8 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): YA 1, 2 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The service user guide provides basic information about the service and the specialist care the home offers. The guide is made available to individuals in a standard format. EVIDENCE: The statement of purpose was not available on request. A copy of the service user was available but has not been reviewed since July 2004. The service users guide does not contain all the relevant information to assist with making an informed choice about the home with the format and font being difficult to read. Both documents must contain the current information of the service provision, be produced in a format suitable for the service users group, be readily available and reviewed on a regular basis. Two case files selected for inspection each contained assessments made by the primary care trusts and the home prior to offering and accepting a placement. Information is based on the person centred approach with personal history obtained. The clients and/or representatives are fully involved with the admission and care planning procedures. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 9 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): YA 6,7,9 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Care plans are developed following person centred planning principles, each service user has a plan that has been agreed with him or her. EVIDENCE: Each case file contained a full plan of care initially based on the preadmission assessments. The plans are reviewed, revised and updated on regular basis with the full involvement of the service user. One care plan identified a particular need for personal care and included good information of skin and hair care. Included in both case files was a management strategy for dealing with inappropriate and challenging behaviours. This was supported by information for staff, on how to deal with any potential and actual challenging behaviour in a non-confrontational style. All risk assessments and the actions needed to reduce the risk are carried out with the full agreement of the service user. An annual review was in process with a service user, relatives, social worker and staff from the home. The case files contained the information of the annual reviews and recorded any actions identified from the review. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 10 Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 11 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): YA 12,13,15,16,17 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The working practice of staff promote individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. EVIDENCE: One case file contained details of a service user attending a sheltered workshop, day care centre and the one to one support sessions offered at the home. All service users are actively encouraged to access the facilities in the local community. The amount of support needed from the staff is assessed on an individual basis. A social and recreational programme includes visiting the gym, swimming, library and shopping. In house recreational activities based on personal preferences include DIY, gardening, music and television. Staff confirmed that service users are actively encouraged to maintain contact with their friends and family and many activities are arranged in the community offering the opportunity for meeting other people. The daily routines are arranged to the capabilities of each individual. Staff state that service users do not attend to their own laundry or cook their own Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 12 meals. These tasks are carried out by the staff. A small kitchen area is available for service users to make their own drinks. Service users were observed to be making tea and coffee throughout the morning. The meals are provided in consultation with the service users, staff state that most days the service users have their main meal at the day centres, the majority of the meals are snack type. One service user stated that the food was ‘ok and always enough of it’. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 13 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): YA 18,19,20 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The personal and health needs of service users are very well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis EVIDENCE: The amount of personal support provided by the staff is identified with the service users and recorded in the care plan. Staff demonstrated a good knowledge of the different preferences and needs of the individuals. The case files evidence access to health care facilities, with recording of regular visits to the G.P., dentist, chiropodist etc and when needed to specialist services, speech therapist, addiction services, clinical psychologists and psychiatrists. The home operates a twenty-eight day regime of medication administration using a monitored dose system with some bottles and boxes. Medication is kept to a minimum with surplus medication being returned to the pharmacy each month. All medications received into the home are documented on the medication administration record sheets (MAR), and these appeared to be correctly completed. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 14 All staff have completed training in the safe handling of medication and again demonstrated a good knowledge of the procedures and the individual requirements. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 15 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): YA 22,23 Quality in this area is average. This judgement has been made using available evidence including a visit to this service. The homes complaints and adult protection procedures are satisfactory. EVIDENCE: The service users guide contains information on how to make complaint. The telephone number of the Commission for Social Care Inspection office is included. The acting manager confirmed that no concerns/complaints have been raised with the home; no concerns have been directed to Commission for Social Care Inspection since the last inspection in June 2006. Training in adult protection was available for staff in January 2006; staff members stated that they found the course to be ‘extremely informative’. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 16 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): YA 24,30 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable, and has a rolling programme to improve the decoration, fixtures and fittings. There is slippage of timescales and maintenance tends to be reactive rather than proactive. EVIDENCE: The home is continuing with the refurbishment programme, all bedrooms have been redecorated, as have the hall stairs and landing. Staff stated that service users have been consulted in the choice of décor for their bedrooms. The drive at the front of the house has been repaved. The deputy manager explained that the communal areas are next to be redecorated with the service users kitchen being refitted with new units. The utility areas will follow on. The carpets will be replaced when the decorating is completed. At the last inspection a date of 31st August 2006 was agreed for the complete refurbishment of the property. A revised date of 1st October 2006 was agreed with the deputy manager and inspector. A wooden wedge was holding open one of the bedroom doors on the first floor. Where there is a need or personal preference for communal or private area Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 17 doors to be kept open then the appropriate door closure, which is linked into the fire alarm system, must be fitted. The toilet seat in the first floor bathroom is chipped and damaged. The deputy manager explained that the whole bathroom is planned for a refit. Nevertheless the toilet seat must be replaced to reduce the risk of injury. Cloth towels, bars of soap and toiletries were in use in the communal toilets and bathrooms. Paper towels, liquid soap and a lidded disposal bin must be provided in these areas to reduce the risk of cross infection. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 18 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): YA 32,34,35 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure that clearly defines the process to be followed which ensures the delivery of good quality services and for the protection of individuals. EVIDENCE: The deputy manager and the two care staff appeared to be very knowledgeable in the management and care of the current service users group and discussed the challenges associated with mental ill health and associated conditions. Staff explained the level of staffing is dependent on the needs of the service users and is constantly being reviewed in line with the care needs of the individuals. The staff personnel file selected for inspection contained certificates for National Vocational Qualification level 2 in care, safe handling of medication, Emergency first aid and moving and handling. Identity checks, references and criminal record bureau disclosures were available in the personnel file. The deputy manager explained that the requirement made at the last inspection for staff to receive training in the prevention/management of physical/ verbal aggression has yet to be arranged for staff, but is planning on contacting the local college in September. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 19 Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 20 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): YA 37,39,42 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed to the benefit of the residents. There are clear lines of accountability within the home. EVIDENCE: The manager was not at the home during the course of the inspection, but discussions with the deputy manager and staff and observations of records suggest that the home is being managed well. One service user stated that she found the manager to be approachable and ‘ok’. The deputy manager stated that the quality assurance and monitoring systems are being developed for 2006, and confirmed the ongoing programme for the refurbishment plan. Documentary evidence is available for promoting and protecting the health, safety and welfare of service users, staff and visitors. Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 21 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 1 2 3 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 3 23 2 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 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 22 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. 1 Standard YA1 Regulation 4(1)(2) Requirement Timescale for action 30/09/06 2 YA1 2. YA24 The statement of purpose must be readily available, contain the current and required information and in a suitable format for the service users group. 5(1)(2) The service user guide must be readily available, contain the current and required information and in a suitable format for the service users group. 23(2(b)(d) The proposed refurbishment/ redecoration/re-carpeting plan must be completed. Previous timescale 31/08/06 not fully met. 23(4) Wooden wedges or pieces of furniture must not be used for keeping communal or private area doors open The toilet seat in the first floor bathroom must be replaced. Appropriate hand washing facilities must be available in communal bathrooms and toilets. All Care Staff must complete accredited training in prevention/management of verbal/physical aggression. DS0000020543.V306695.R01.S.doc 30/09/06 31/08/06 3 YA24 31/08/06 4 5 YA24 YA30 13(4) 13(3) 31/08/06 31/08/06 6 YA23 13(6) 30/09/06 Charter House Version 5.2 Page 23 Previous timescale 31/07/06 not fully met. 7 YA39 24(1) The home must develop and maintain an effective quality assurance and monitoring system. 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charter House DS0000020543.V306695.R01.S.doc Version 5.2 Page 24 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.V306695.R01.S.doc Version 5.2 Page 25 - 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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