Inspection on 11/02/10 for Charterhouse Residential Care Home

This inspection was carried out on 11th February 2010.

CQC found this care home to be providing an Poor service.

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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charterhouse Residential Care... 14/05/10

Charterhouse Residential Care... 15/09/09

Charterhouse Residential Care... 22/01/09

Charterhouse Residential Care... 11/11/08

Charterhouse Residential Care... 05/07/07

Charterhouse Residential Care... 27/07/06

Charterhouse Residential Care... 23/11/05

Charterhouse Residential Care... 08/06/05

Charterhouse Residential Care... 03/02/05

Charterhouse Residential Care... 02/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 03/06/2010.

Key inspection report Care homes for older people Name: Address: Charterhouse Residential Care Home Second Drive Dawlish Road Teignmouth Devon TQ14 8TL     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Judy Hill     Date: 1 1 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Charterhouse Residential Care Home Second Drive Dawlish Road Teignmouth Devon TQ14 8TL 01626774481 01626774481 margaretbrett@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Stephan Barry William Brett,Margaret Louise Brett Name of registered manager (if applicable) Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Charterhouse provides accommodation and care for a maximum of twenty people in the registration categories of old age, dementia, physical disabilities and mental illness. The home does not provide nursing care. A partnership of Mr Stephan Brett and Mrs Margaret Brett are registered as the service Care Homes for Older People Page 4 of 39 Over 65 20 20 20 20 0 0 0 0 1 5 0 9 2 0 0 9 Brief description of the care home providers. A manager has been appointed to manage the home on a day to day basis but the Care Quality Commission has not received a completed application to register this person. Charterhouse is a large detached period property set in landscaped gardens. It is less than a mile from the town, which has a good beach, railway station and frequent bus services. The fees range from £330 to £468 a week. Extra costs include private hairdressing, private chiropody and items of a personal nature. Information about the home including a copy of the last inspection report can be obtained on request from the Home. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Two regulatory inspectors carried out an unannounced visit to the home on 11th February 2010. During this visit we toured of the premises. We also carried out two direct observations of how the service operates using dementia care mapping tool and also indirectly observed how the home operates. We spoke with the unregistered manager and the staff on duty and interviewed two members of staff in private. We saw all of the people who use the service and spoke with most of them. We also looked at some of the homes records including residents needs assessments and plans of care, staff training records, staff rotas and medication administration records. Before the site visit we send questionnaires to home to be given out to some of the people who live at Charterhouse, people who visit the home in a professional capacity and people who work at the home. The information we received from the questionnaires that were completed and returned to us was used to help plan the inspection and to write the report. We also used the report of the last key inspection, Care Homes for Older People Page 6 of 39 which included a site visit that was carried out on 15th September 2009 and the homes Statement of Purpose and Service User Guide for this purpose. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guides need to be redrafted because they do not provide current and prospective residents and their representatives with all of the information they need about the home and the service provided. The homes individual needs assessments, care plans and risk assessments need to be more detailed and reviewed regularly. This is to enable peoples needs to be fully identified and their changing needs to be recorded and met. Better security needs to be provided for the residents personal files and their medicines. This is to ensure that personal information about the residents can only be accessed on a need to know basis and to prevent unauthorised access to medicines. Prescribed creams must only be used by people they are prescribed for. Care Homes for Older People Page 8 of 39 More could be done to enable people to go out in groups or on their own with a staff escort. This would help people to feel part of the local community. The garden is not secure, accessible or safe for the residents to use unattended. The door bell, which was not working on our last visit to the home September 2009, was still not working at the time of this inspection. This makes it difficult for visitors to be heard by the staff. The premises are not considered to be secure as both the outer and inner door to the home are not kept locked so visitors can walk into the home undetected by the staff. People who use the service may not have access to a call bell from their bed or from their bedroom chair. This means that they may not be able to call for staff assistance when they need to. There are not always enough staff on duty to meet the needs of the residents. This means that the residents needs are not always met. The provision of staff training is poor. This means that the staff may not have the knowledge and skills they need to care for the residents. The person who is employed as the manager of the service has not made an application to be registered with us. The providers who are registered at present have not been involved in the day to day running of the home and we have been told that they have had very little contact with the senior person in charge. We understand that this situation has changed since the inspection. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 39 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not given the information they need to enable them to make an informed decision about whether or not the home will be able to meet their needs. Internal needs assessment practices do not focus sufficiently on identifying peoples individuality and diversity. Evidence: During the site visit we asked for a copy of the Statement of Purpose. The document we were given does not contain all of the information that is required to be included under the Care Homes Regulations or that is recommended to be included under the National Minimum Standards. This means that people who are considering using the service and their representatives are not being given all of the information they should be given about the home and the service provided. Since the inspection the registered providers have told us that they consider the Statement of Purpose to be up to date, apart from a change to the name and address Care Homes for Older People Page 11 of 39 Evidence: of the regulating authority. We also asked for and were given a copy of the Service User Guide. People who use the service had been given a copy of the Service User Guide but again this document did not include all of the required and recommended information. This means that the people who use the service and their representatives are not being given all of the information they should be given about what to expect from the service. Since the inspection the registered persons have told us that the Service Users Guide will be updated. During our previous inspection, which included a site visit that was carried out on 15th September 2009, we looked at three of the residents needs assessments. For each of these people a care management or joint assessment had been obtained from the local authority or care trust arranging the admission and a basic pre-admission assessment had been carried out by the home. We recommended that the homes needs assessment was completed in more detail to help to define who the person is and identify the diversity of their individual needs. During this inspection we looked at the needs assessments of the two people most recently admitted. Both had been placed at the home by the local authority for respite care and care management assessments had been received by the home. In depth internal needs assessments, which are an important part of the needs assessment process because they help to define who the person is and identify the diversity of their wishes and needs had not been carried out. We also looked at the needs assessment for a private resident who had lived at the home for over four years. Her needs assessment did not provide the depth of information needed to form the basis of a detailed and person centred plan of care. Care Homes for Older People Page 12 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the staff are clearly very caring, the care planning practices are poor and do not provide them with the guidance they need to provide a service that is based on peoples individually assessed needs. Evidence: During our last inspection we looked at the plans of care of four of the people who use the service and found that these were poorly constructed. During this inspection we looked in depth at one plan of care, this was for a resident who has dementia and has lived at the home for over four years, and the same picture emerged. The plan of care contained very little information about the resident and some of the information that was included did not match how the service was being provided in practice. For example, the care plan described the resident as being Diabetic, diet controlled, but when we spoke to the cook we were told that none of the residents were diet controlled diabetics. A moving and handling assessment was seen but this was dated 29th November 2008. Care Homes for Older People Page 13 of 39 Evidence: This information was still current, but we saw no evidence that any reviews had taken place. A risk assessment had been carried out on 5th February 2009 concerning an extremely hot and uncovered radiator in a ladies bedroom. This recorded very likely or possible risk of severe or moderate scalding. A radiator cover had not been fitted to remove the risk and the recorded action stated that the identified risk remained under review. During the site visit we made an immediate requirement to fit a radiator cover and have received confirmation that this has been complied with. The plan of care stated that the lady was Continent but there were incontinent pads in her bedroom and the room, most notably in the en-suite toilet, smelt strongly of urine. During the site visit we carried out two short observations using a dementia care mapping tool. The first of these lasted forty-five minutes and was carried out in the sitting room. The second was carried out in the dining room for 30 minutes during lunch. In contrast to the poor care planning and reviews, we found that the staff interaction with the residents was generally good and included bending to speak to people and hand touching to get a persons attention. People were asked if they wanted tea or coffee and a biscuit and later asked if they would like a second cup and more biscuits. It appeared that people have regular fluids available to them as following hot drinks people were offered a choice of cold drinks and these were left with them to drink as and when they chose to. People were assisted out of the lounge, presumably to the toilet, but this was done discretely to avoid embarrassment, which is good practice. However, the standard of moving and handling was poor because little instruction was given to people and the staff assisted by holding people under their arms. We did not see a handling belt being used although we were told that handling belts were available. It was noted that since the last inspection the bath in the ground floor bathroom had been removed making access to the toilet easier and safer for people who use wheelchairs and walking frames and for the staff assisting them. Arrangements are being made for people to receive help when they need it from the professional health care services and during the site visit two community nurses were seen visiting the home. We also received a completed survey back from a GP, which Care Homes for Older People Page 14 of 39 Evidence: was very positive about the quality of care provided. During our formal observations the staff rarely addressed people by name but instead called them Darling, Sweetie, etcetera and we overheard two people telling different residents that they were a Good Girl. Although no-one appeared to object to this form of address, it is not good practice and could be considered demeaning. In response to a recommendation made in the last inspection report the medication trolley had been moved from the dining room. This was repositioned to an area of the entrance hall that has been sectioned off to provide a work station for the staff. The trolley had not been secured to the wall, but a chain had been fitted indicating that this would be done. There are two keys to the medication trolley, one was being held by the most senior person on duty, which is the correct procedure, second had been placed in an unlocked drawer in the workstation. This means that anyone entering the home could gain access to the medicines. The home has a controlled drugs cabinet and a medication fridge but these were not needed at the time of the site visit. The home uses the Lloyds pharmacy controlled system to order, administer and dispose of medicines. The trolley was found to be neat and orderly and we saw no out of date stock in it. We looked at the medication administration record sheets and it was possible to follow the prescription and administration arrangements. However, the medicines had not been booked into the home as they must be for a full audit. We were told that medicines were usually booked in and we saw records where this was so. We saw that codes had been used to identify a reason why if medicines had not been administered as prescribed and medicines that had been given were fully signed for. There were no signatures to tell us who had handwritten prescription information for a recently admitted resident, or that the accuracy of this information had been verified by a second person. There was no plan of when PRN medicines should be taken, in this case paracetamol, so staff would not necessarily be consistent in their use and this could be open to mistakes or mishandling. Prescribed creams are stored in a locked cupboard in the same area and in bedrooms or en-suite toilets. We found that the home had a surplus of prescribed creams. In one en-suite toilet we found several creams that had had the name of the person they were prescribed for removed and other jars of cream that had been prescribed for a resident who had recently passed away. We discussed this and were assured that opened creams had not been used by more that one resident. We were told that unopened jars of prescribed creams had been used by people who are prescribed the Care Homes for Older People Page 15 of 39 Evidence: same creams to avoid waste. At our request immediate action was taken to remove creams that were not being used by the person they were prescribed for and an assurance was given that this practice would stop. Since the inspection the registered providers have told us that all creams and medicines which were not prescribed for cyrrent residents have been returned to the Pharmacist. Care Homes for Older People Page 16 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given opportunities to engage in activities within their home but have very few little provision is made to enable them to go out into the community. Poor care planning and reviews mean that peoples special dietary needs may not be known or catered for. Evidence: Regular in house activities which are facilitated by the staff take place in the lounge every day. These include skittles, bingo, quizzes and painting as well as passive activities, such as watching television and listening to music. A game of bingo was observed being played during our visit. There are plenty of books around for people to read if they wish to do so and a piano and games for people to play. Photographs and pictures of things which would have been familiar to people in their younger days were displayed in the communal rooms, which helped to give the room a homely feel. No restrictions are placed on visitors by the home and during the inspection we saw that visitors were made to feel welcome by the staff and residents alike. One visitor stayed for some time and spoke with several people during his visit. Care Homes for Older People Page 17 of 39 Evidence: A Church leader has been visiting on a regular basis for seven years to lead short services at the home. He told us that he had always found the residents to be well cared for by the staff and that they appeared happy and contented. Very occasionally group outings are arranged, one of which had been a trip to the local theatre, but generally people are not able to participate in activities outside their home unless they have friends or families to escort them. Even use of the garden is restricted because it is not enclosed and access from the house is hazardous. There is an enclosed terrace area next to the house which people can use safely, and some people need assistance to access this facility safely. The dish of the day had been written up on a notice board in the dining room and two of the people we spoke with said that they had also been told what was for dinner. People are not offered a choice of set meals, although we were told that alternatives would be found if requested. We asked the cook if any of the residents had any special dietary requirements and were told that although four of the residents are diabetic, their condition is not diet controlled. This contradicts the information seen on a residents care plan which identified her as a diet controlled diabetic. Since the inspection the registered persons have confirmed that the cooks did not have a record of the people who are diet controlled diabetics and told us that they have now been provided with this information. We used an observational tool to observed the lunch being served and eaten in the dining room. There were two staff in the dining room serving the meals. They were attentive and helped people with seating and cutting their food where help was needed. They offered gravy to each of the residents whose meals were already plated. Each interaction was kindly and helpful and this appeared to be completely genuine and normal practice. We were told that one of the residents preferred to eat her meals in the lounge and that her wishes were respected. This lady clearly needed help to eat her meal but as there were only two care staff on duty and they were busy in the dining room, she was not given the help she needed in a timely manner. We looked at the staff rota and this told us that three care assistants should have been on duty over the lunchtime period, which would have provided enough care staff to meet the needs of the residents. However there were only two care assistants on duty over the lunchtime period. Care Homes for Older People Page 18 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Lack of staff training on the protection of vulnerable adults could place people at risk of abuse. Evidence: The Complaints procedure is displayed in the entrance hall and the registered provider has told us that any complaints will be acted upon within twenty-eight days. Surveys that were completed and returned to us by three of the people who work at the home all stated that the staff would know what to do if any of the residents had any concerns or complaints about the service. We asked if any complaints had been received by the home since our last inspection, which was carried out six months previously, and were told that none had. No safeguarding referrals had been made since the last inspection and the staff were seen to be considerate and caring when working with the residents. However, we looked at the staff training records and saw no evidence that the staff had received any training on the Protection of Vulnerable Adults or that this had been planned. Care Homes for Older People Page 19 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The communal rooms are clean and homely. Further maintenance work is needed to bring the home up to a good standard but improvements have been made since the last inspection. Evidence: There is a long driveway up to the house and this provides ample off road parking for staff and visitors. Alongside the driveway there is a large lawn, which is bordered by mature shrubs and trees. A wall provides security on two sides of the garden but the side next to the drive is not enclosed. This, and the difficult access to the lawned garden from the house, prevents the residents from using this valuable asset independently for recreation and exercise. There is an enclosed terrace next to the house that the residents can use, although some of them would need assistance to access this area. Both the front door bell and the door bell in the inner lobby were not working, but as neither door was locked it was possible to walk into the home without attracting the attention of the staff. A combination lock on the inner lobby door prevents the residents from leaving the premises without staff assistance, but we did not see any individual risk assessments to justify locking the residents in or anything to tell us how people can enter and leave their home as and when they choose to do so, which is their legal right. Care Homes for Older People Page 20 of 39 Evidence: There is a large entrance hall which has seating in it. This is well used by some people as an alternative from the lounge. There is a pay phone in this area for the residents to use to make and receive calls. If people want to use the phone privately, a cordless phone is available to enable them to do so from their bedrooms. Part of the entrance hall has been sectioned off to provide a work station for the staff. Care plans are kept out of view in this area but we were concerned about the security of this arrangement as this area is not lockable. The lounge is off the entrance hall and was seen to be very domestic and people told us they were comfortable using the room. The provision of a well stocked and spotlessly clean tank of fish, budgies in very clean cages, books, games and bric a brac items helped to create a pleasant sense of homeliness. However, the surveys completed and returned to us told us that there were not enough chairs in this room to accommodate all of the residents and that people were sometimes made to feel excluded. We checked this and found that there were only fifteen chairs for the seventeen people who were currently living at the home. There is however a conservatory which is used as a second lounge. Considerable improvements had been made to the dining room since our last visit. The room had been redecorated, a shrub that was blocking much of the light from a large window had been pruned back and the medication cabinet had been removed. This room now has a much more homely feel to it and provides a very pleasant room for the people to eat their meals in. There is a conservatory that can be accessed from the lounge or the dining room. This room is spacious, homely and comfortably furnished although little used in the winter months because it is single glazed and difficult to heat. Since the inspection a new radiator has been fitted to help heat the room. The carpets in the communal areas are very heavily patterned and consideration should be given to replacing these with plain carpets, which would make it easier for people with dementia to interpret and use the surface they are walking on. Since our last inspection the bath, which was making it very difficult for people who use wheelchairs and walking frames to access the only communal toilet on the ground floor has been removed and this has solved the problem of accessibility. However, this does mean that there is now only one communal bathroom in the home, which can accommodate up to twenty people. This bathroom is on the first floor, but is accessible because the home has a passenger lift. The bathroom has a fixed hoist to Care Homes for Older People Page 21 of 39 Evidence: enable the staff to assist people safely. There are two toilets on the first floor. One, which does not have a hand washing basin in it and is reserved for staff use only and there is a second staff toilet, which is not accessible for the residents because it is beyond a door which has been fitted with a combination lock, on the ground floor. All of the bedrooms are adequately furnished and decorated and most of them have been personalised by the people who use the rooms. Some of the bedrooms have pressure mats that will alert the staff if people get out of bed during the night and so help to reduce the risk of falls. However, we were told that a shortage of sockets means that some of the residents call bells have been disconnected to accommodate the pressure mats. In some rooms where the call bells had not been disconnected, they were not positioned to enable people to reach them from their beds or did not have extension leads to enable people to use them from their easy chairs. One person did have an extension lead to enable her to call for staff assistance from her chair but this trailed dangerously across the floor. During our tour of the premises we noted that several radiators in peoples bedrooms and in the halls and corridors had not been covered. These were found to be extremely hot and pose a severe risk to the residents, in particular to people who have dementia and are ambulant. We have discussed this with the service provider who has agreed to fit covers to all radiators within the next five months. The kitchen is spacious and well equipped to cater for the needs of the home. The laundry facilities are in the basement and approached via steep steps which make it inaccessible to the residents. Since our last inspection a double sink has been fitted. The washing machines have a sluicing facility and are capable of reaching temperatures high enough to kill bacteria. Carpet tiles in the laundry are still in place but we have been told that these will be removed and that the concrete floor would be coated with two coats of liquid concrete paint by March 2010. Since this inspection the carpet tiles in the laundry have been removed. During our last inspection we found areas of the home to be dirty. This was partly due to insufficient cover being provided for the housekeeper who was on leave at the time. During this inspection the housekeeper was not on leave and we found the home to be clean and fresh throughout, with the exception of one bedroom which has been mentioned elsewhere. During our visit we did observe that the cleaning trolley had been left unattended in the hallways on several occasions. This is not safe practice in a home that caters for Care Homes for Older People Page 22 of 39 Evidence: people who have dementia and are ambulant. Care Homes for Older People Page 23 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels are not always high enough to meet the needs of the residents and the care staff are not provided with the training they need to do the work that is expected of them. Evidence: The staff turnover had been low since the last key inspection and the issues that were identified concerning uncompleted Criminal Record Bureau checks have been resolved. This means that the practices used to recruit new care assistants are now considered to be safe. We asked for and were given copies of the staff rota for a four week period from 18th January to 14th February 2010. These told us that there are usually three care staff on duty from 8am to 2pm, two from 2pm to 5pm and three from 5pm to 8pm. In addition to this a chef is employed for five to six hours a day and a housekeeper for six hours a day from Monday to Friday only and a manager, who is not registered, is employed to work from 8am to 5pm from Monday to Thursday and from 8am to 2pm on Fridays. On the day of our visit we met the chef and the housekeeper. The staff rota, which should provide an accurate record of the staff on duty at any given time told us that there should have been three care staff on duty from 8am until 2pm. However, we Care Homes for Older People Page 24 of 39 Evidence: were told that one care worker left at 11.45am, leaving just two care workers on duty until 5pm. There were seventeen people living in the home at the time of our visit and although two care workers were attentive and met the needs of the residents well most of the time, an additional person was needed during the lunchtime period as three people required help to eat their meals and only two members of staff were available to assist them. Also with only two care staff on duty from 2pm to 5pm, the staffing levels would not be high enough to enable people to go out into the community with a staff escort if they chose to do so. Most of the people who live at Charterhouse have dementia and we would, therefore expect them to need assistance or prompting to help them wash, dress and undress. With only one member of staff on waking duty from 8pm to 8am we do not consider the late evening, overnight and early morning staffing levels to be high enough to meet their needs. The surveys that we received from three members of staff indicated that the provision of staff training was good. However, our discussions with the unregistered manager and staff during the inspection and our observation of some care practices identified that some of the staffs training needs had not been met. For example, the methods seen being used by some of the staff to assist people with their mobility were poor, which indicates that updated training is needed. The staff training records told us that all of the care staff had received training in Nutrition and First Aid and for six of the ten care staff whose staff training records we looked at this was the extent of their recorded training provision. Three people had received training on Moving and Handling, one on Infection Control, four on Parkinsons disease and one on sensory deprivation. None of the staff were recorded as having attended training on Dementia Awareness, although the unregistered manager said that she hoped to be able to book six people to attend this training course. We were told that some people had attended training on medication administration but did not see a record of this and we were told that Fire Safety training was due to take place shortly. We saw no evidence of training provision on Safeguarding Adults, Equality and Diversity, Deprivation of Liberties or Health and Safety. Since the inspection the service providers have told us that further training is planned. Care Homes for Older People Page 25 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration arrangements at Charterhouse are inadequate and this is placing the people who work at the home and the people who use the service at risk of harm. Evidence: The registered persons in control are Mr Stephan Brett and Mrs Margaret Brett. The certificate of registration that is displayed in the entrance hall of the home is not the most recent certificate of registration. A manager was appointed in April 2009 and is still in post. However, to date she has not submitted a completed application to be registered. This means that the Care Quality Commission has not been given the opportunity to formerly assess her suitability for the post. Mr and Mrs Brett have visited the home periodically since the last inspection but are Care Homes for Older People Page 26 of 39 Evidence: not involved with the day to day running of the home. They have not carried out unannounced monitoring visits to the home once a month or produced regular written reports on the conduct of the care home. This is a requirement under regulation 26 of the Care Homes Regulations. This means that the management oversight has been poor. Although questionnaires were seen to have been used to gain feedback from the people who use the service and their representatives, this information has not been used to form a development plan based on a systematic cycle of planning - action review. This means that there is no effective quality assurance and quality monitoring system, which reflects the aims and outcomes for the people who use the service in place. The people who use the service are encouraged to seek support from their families, friends or legal representatives to handle their personal financial affairs, which is good practice. The home does look after small amounts of personal spending money for some of the residents and records are kept of any money deposited for safekeeping or spent by the individual or on their behalf. The home does not have all of the policies, procedures or codes of practice that are required or recommended to be kept at the home and very little staff training has been provided. This means that some members of staff may never have received training in Safeguarding Adults, Dementia Awareness, Infection Control, Fire Safety, Moving and Handling, Health and Safety, Basic Food Hygiene, Tissue Viability, Safe Handling of Medicines and Continence Control or that their training may be out of date. Care planning was seen to be poorly documented and we saw no evidence that regular reviews of peoples individual needs are being carried out and recorded. This has resulted in conflicting information being presented which is confusing and could have serious implications for the wellbeing of individual residents. Examples mentioned previously in this report include a resident whose care plan stated that she is a diet controlled diabetic, when the chef had told us that none of the residents were diet controlled diabetics and the resident who was described as continent, but was using incontinence pads. Although some risk assessments had been carried out, action had not always been taken or guidance recorded to minimise the risk. An example of this was the risk assessment that stated that a resident was at risk of scalding herself on the hot radiator in her bedroom but the radiator, which has been covered since our inspection, Care Homes for Older People Page 27 of 39 Evidence: remained uncovered for over a year. We saw call bells in the bedrooms but these were not always accessible to people from their beds or easy chairs and we were told that some of the call bells were not connected. This means that people may not be able to call for staff assistance from their bedrooms, which could place them at risk. We were also concerned that the care staffing levels were not always high enough to meet the needs of the residents. Most of the people who use the service have dementia, which means that they have higher than average care needs. Care Homes for Older People Page 28 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 The registered persons must 30/12/2009 ensure that the residents care plans are regularly reviewed. Monthly reviews are recommended. This is to ensure that peoples care plans can be adjusted to meet their changing needs. 2 8 18 The registered persons must 30/12/2009 ensure that the staff receive the training they need to carry out their duties safely. This refers specifically to training in continence control and continence management, lifting and manual handling, dementia care, medication administration, safeguarding and managing aggressive behaviour. This is to ensure that peoples assessed needs can be met safely. 3 12 23 The registered providers 28/11/2009 must ensure that the external grounds are suitable for and safe for use by the people who use the service. This is to ensure that people can use the gardens when they wish to safely. Care Homes for Older People Page 29 of 39 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 4 19 23 The registered provider must 01/11/2009 provide accessible call bells in all of the bedrooms. This is to ensure that people have access to staff support at all times. 5 22 13 Suitable arrangements must be made to provide a safe system for moving and handling residents. To protect the residents and staff from harm. 27/03/2009 6 27 18 The registered persons must 28/10/2009 ensure that enough staff are employed at all times to meet the assessed needs of the residents. This is to ensure that the people living at the home have the care they need. 7 27 18 Having regard to the size of the home and the number and needs of the residents, suitably qualified staff must be employed in sufficient numbers to meet the needs of the residents at all times of the day and night. To ensure that the needs of the residents can be met. 27/03/2009 8 30 18 Ensure that the staff are 15/03/2009 given training that is appropriate to the work they are to perform. To ensure that the staff have Care Homes for Older People Page 30 of 39 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action the skills they need to meet the needs of the people who use the service. 9 30 18 The registered persons must 28/12/2009 ensure that the staff receive the training they need to enable them to carry out the duties that they are required to perform safely. This is to ensure that the people living at the home receive the care they need. 10 33 24 The registered persons must 28/12/2009 establish and maintain a system for reviewing and improving the quality of care provided at the home. This should be done by consulting the residents and their representatives and by producing an annual development plan for the home. This is to enable the people using the service and their representatives to influence the way the service develops. Care Homes for Older People Page 31 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 The registered persons should rewrite the Service Users Guide and include all of the information that is required in the Care Homes Regulations and recommended in the National Care Standards in it. This is to provide the people who live at the home with the information they need about what they should expect from the service. 11/06/2010 2 1 4 The registered persons 10/06/2010 should rewrite the Statement of Purpose and include all of the information that is required by the Care Homes Regulations and recommended in the National Minimum Standards to be included. This is the ensure that people considering using the Care Homes for Older People Page 32 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action service and their representatives have the information they need about the home and the service provided. 3 7 13 The registered persons must 11/06/2010 ensure that unnecessary risks to the health and safety of the residents are identified and so far as possible eliminated by carrying out individual risk assessments and producing written guidance on how the risk can be eliminated or reduced. This is to protect the people who use the service from harm. 4 7 12 The registered persons must 11/06/2010 ensure that the home is conducted so as to promote and make proper provision for the care of the residents. This includes identifying and recording peoples individual needs and drawing up care plans to provide guidance on how to meet peoples needs. We recommend that needs assessments and care plans are reviewed at least once a month. Care Homes for Older People Page 33 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure that peoples individual needs are identified and can be met. 5 9 13 The registered persons must 11/06/2010 ensure that the medicine trolley is chained to a solid wall, that the keys are carried by the most senior person on duty and that any spare keys are not left in an unlocked drawer. This is to ensure that medicines are kept safe and secure. 6 12 23 The registered persons must 11/06/2010 ensure that the external grounds are suitable for or safe for use by the people who use the service. This is to ensure that people can use the gardens when they wish to do so. 7 19 12 The registered persons must 11/06/2010 ensure that each of the residents has a call bell that is accessible from their bed and from their chair to enable them to call for staff assistance if they need to. This is to ensure that people have access to staff assistance at all time. Care Homes for Older People Page 34 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 8 19 12 The registered persons must 11/08/2010 ensure that the home is safe for the residents by fitting radiator covers. This is to remove the risk of people scalding themselves. 9 27 18 The registered persons must 11/06/2010 ensure that there are enough staff on duty at all times to meet the needs of the residents. This is to ensure that the people living at the home have the care they need. 10 30 18 The registered persons must 11/06/2010 ensure that the staff have access to the training they need. This training should include Health and Safety, Medication administration, First Aid, Food Hygiene, Infection Control, Manual Handling, Continence Care, Dementia Awareness and Safeguarding Adults. This is to ensure that the staff have the knowledge and skills to do the work that is expected of them. 11 31 26 One of the registered persons must carry out monthly monitoring visits to the home and prepare a 12/04/2010 Care Homes for Older People Page 35 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action written report on the conduct of the home. This is to enable the service providers to oversee the management of their business. 12 33 22 The registered persons must 11/06/2010 establish a system for reviewing and improving the quality of care provided at the home. This should be done by consulting the residents and their representatives and by producing an annual development plan for the home. This is to enable the people using the service and their representatives to influence the way the service develops. 13 38 12 The registered persons must 11/06/2010 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of the people who use the service. This includes: Ensuring that the premises are safe and suitable for the people who use the service. That sufficient numbers of Care Homes for Older People Page 36 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action staff are employed and that the staff receive appropriate training to carry out the work that is expected of them. That policies, procedures and codes of practice are in place to provide guidance for the staff. And, by providing strong management and management oversight. This is to ensure that the service is able to provide a safe home for the people who use it. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 When completing peoples needs assessments, their religious and cultural needs, social interests, weight and dietary needs should be included as these help to define who the person is and identify the diversity of their individual needs. To preserve the dignity of the people who use the service, they should be addressed by their preferred names and not automatically called Darling or Sweetie or told that they are a good girl. People should be given the opportunity to engage in group or individual activities outside their home with the assistance of staff if necessary. People should be offered a choice of at least two different dishes at each mealtime and offered alternatives if they do not want either of the set meal. Page 37 of 39 2 10 3 13 4 15 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 5 19 The carpets in the communal rooms are not suitable in a home that provides care for people with dementia as they are heavily patterned. Consideration should be given to replacing these with plain carpets. The front and inner doorbells should be repaired or replaced and a suitable lock should be fitted to one of the front doors to prevent people entering the home without being detected. All domestic chemicals should be stored away safely and not left unattended in the home. 6 19 7 26 Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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