Inspection on 21/11/06 for Charton Manor

This inspection was carried out on 21st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charton Manor 27/02/09

Charton Manor 09/01/06

Charton Manor 30/08/05

Charton Manor 13/12/04

Charton Manor 29/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Charton Manor Gorse Hill Farningham Kent DA4 0JT Lead Inspector Elizabeth Baker Key Unannounced Inspection 21st November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charton Manor Address Gorse Hill Farningham Kent DA4 0JT 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) 01322 863116 01322 866248 mail@chartonmanor.org www.chartonmanor.org Hawthorne Trust Limited Mrs Ednah Lawal Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Care may also be provided to a number of service users who are over 18 years on admission. All service users must be willing to rely on Bible based healing known as Christian Science. There is a maximum of 17 service users requiring Christian Science nursing care and/or Christian Science care and/or rest and study on a short-term basis. 9th January 2006 Date of last inspection Brief Description of the Service: Charton Manor is a facility registered solely for Christian Scientists who require non-medical nursing care and or study and rest for short-term periods. The facility’s Statement of Purpose states Charton Manor provides 24 hour shortterm Christian Science nursing care to men and women aged 18 and over who have chosen to rely solely upon the Bible-based method of spiritual healing, Christian Science. This is set out in Science and Health with Key to the Scriptures by Mary Baker Eddy, the Discoverer and Founder of Christian Science. Hawthorn Trust is the registered provider. Charton Manor is a purpose built facility, which was registered with the Commission on 23 March 2003. Patient accommodation is located on the ground floor. There are 15 single bedrooms and one double bedroom. All bedrooms have ensuite shower/WC facilities and telephone points. All rooms used by patients are connected to the call alarm system. The home sits within a six and a half acre site, made up of woodland and lawns. There is ample car parking for visitors and staff. The home is about two miles from the main M20/M25 inter-junction. The villages of Farningham and Eynsford are nearby and Sevenoaks, Swanley and Dartford are easily accessible by private transport. The term Nurse used throughout this report refers to a person who has completed the Christian Science Nursing Training and whose name has subsequently been recorded in The Christian Science Journal, ie is a Journal-listed Nurse. It does not refer to a nurse qualified or registered with the Nursing and Midwifery Council. Current fees range from £75.00 per day room and board, plus £25.00 per hour for nursing care and are payable weekly. Additional charges are payable for chiropody, newspapers, magazines and professional hairdressing. Copies of the latest inspection reports are available in patients’ bedrooms. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key visit to the home for the inspection period 2006/07. The visit was carried out on 21 November 2006 and lasted approximately eight hours. Lead Inspector Elizabeth Baker carried out the visit. As well as touring the home the visit consisted of talking with some patients and staff and inspecting some records for case tracking purposes. Four patients and three members of staff were interviewed in private. The registered manager provided assistance throughout the visit. Occupancy at the time of the visit comprised six patients requiring Christian Science nursing care and one guest requiring rest and study. In support of the visit, the Commission received comment cards about the service from four patients and three relative/visitors. At the Commission’s request the registered manager completed and returned a pre-inspection questionnaire. Some of the information gathered from these sources has been incorporated into the report. The Commission has not received any complaints about the home. The inspection report template used for this visit is that developed for longterm health and social care for older people. The model uses the criteria set out in the Department of Health’s National Minimum Standards, which underpin good quality care. Charton Manor provides religious non-medical nursing care. The visit was undertaken subject to National Minimum Standards modified for Christian Science establishments. What the service does well: Charton Manor provides a valued and essential service to Christian Scientists. Patients are appreciative of the care and support they receive from all members of staff. Comments received about the service from patients and relatives/visitors included “as a Christian Scientist we rely on prayer for healing. I have received many healings this way”, “excellent meals”; “staff are happy and helpful”, “I have everything I need”; “ask for anything and it is supplied” “staff respond to call bell in seconds”, lovely meals”, “I feel I am definitely improving”, “the home is clean, peaceful and I am well cared for”; “the care and love bestowed upon us is excellent”, “staff are very polite and kind and if you ask for something they see that you get it” and “A very loving atmosphere”. The home and grounds are well maintained. Staff enjoy working at the home and spoke enthusiastically about their roles and responsibilities during the visit. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Service User Guide are good. They provide existing and potential patients with the information they need to make an informed decision about moving into the home. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide, which are regularly reviewed and updated. The documents clearly state that the home does not provide medicines or medical treatments and follows the healing philosophies of Christian Scientists. Patients interviewed at the visit deliberately choose this home in order to practice their faith. As part of the admission process prospective patients receive a telephone enquiry assessment, during which important information is obtained to determine Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 9 whether the patient is suitable for admission. This information helps to inform the patient’s care plan on admission. Christian Science Practitioners also assist patients in the admission process. Patients are provided with terms and conditions of residence. Prospective patients are informed of the current fee charges. However grants towards fees are available to patients where this is deemed appropriate. Full details of how grants are administered are included in the Service User Guide. Because the home is not registered to provide medicine or medical treatments, assistance is provided to patients who may decide to receive such care transferring to appropriate care homes. The home is not registered for intermediate care. Standard 6 is not applicable. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Patients know their views are listened to and their records kept secure to maintain confidentiality. Personal and spiritual goals and needs of patients are met. EVIDENCE: Each patient is provided with a care plan. This is drawn up from the information gathered at the assessment stages. A document, which patients are required to complete, enquires whether patients would like to be involved in the composition of the plan. During an interview with a particular patient it was identified that although the patient would have preferred to be involved, they could not recall having been given the choice. Care plans are now computer generated and it is now the practice to use abbreviations. A glossary of the terms is held at the nurses’ station so all staff involved in care plans are aware of the actual meanings. However this situation may prove problematic if patients were more involved and interested in the content of their care plans. Although the home does not provide medical treatments, comfort aids and pressure sore preventative equipment is provided. The home Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 11 has recently changed some of its equipment following specialist advice on what is considered current good practice. If a patient has a wound, full details of the dressings and support is recorded. Care plans are reviewed and updated weekly. Brief details of patients’ wellbeing are recorded daily. Although patients are admitted to the home on a respite basis only the home has contact details of some dental surgeries, so patients can access dental treatment during their stay if there is a need. Patients are required to sign a re-affirmation statement of their wish to continue with non-medical treatment. This is included on the Terms and Conditions of Residents (renewal version) which longer-term respite patients are required to sign on a monthly basis. Continence assessments are used where there is a need. Moving and handling assessments are included in patients’ records. The home does not administer medications to patients. Standard 9 is not applicable. Staff knock and wait for an answer before entering patients’ bedrooms. This is good practice. Patients spoken with indicated they are treated with dignity and respect. Patients complimented the efficiency and standard of the laundry service, which is carried out inhouse. Patients are taken to hairdressers in the nearby village. A patient described how valuable this service is to her wellbeing and is appreciative that the hairdresser does not pry into her personal situation. A comment card received from a relative/visitor included the additional statement “I am very happy with the excellent quality of care that my [relative] is receiving”. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in this home are good offering both choice and variety to patients. Links with the community are good and generally support and enrich patients’ holistic needs. EVIDENCE: Morning Bible Lesson-Sermons are held and hymns sung in the main lounge Mondays to Saturdays and an afternoon service takes place on Sundays. Patients are free to choose whether to attend or not. Some patients choose to have prayer support in the privacy of their own bedrooms. Patients are able to attend Sunday church services and transport is provided to take them to different facilities in the area. General activities such as arts and crafts, puzzles, board games and film shows are also provided and again patients are free to join in or not. Some patients said how much enjoyment they get either from looking into the grounds from their bedrooms and watching the different wildlife and others spoke about the benefits of walking or being transported around the grounds. Patients can make and receive telephone calls from their bedrooms and this service is much appreciated as it keeps patients connected with families, friends and their Christian Science Practitioners. The home has Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 13 piano in the main lounge and patients are invited to play this. A number of patients take the offer up to the delight of other patients. However one patient indicated they would prefer to receive 100 metaphysical activities as opposed to a mix of activities. Visitors are welcomed at the home. Indeed a patient complimented the home in that their family was invited to take breakfast with them on one occasion as they were passing quite near the home at that time of day. Patients are admitted on a short-term basis only. However rooms visited had been individualised with some personal effects to make their stay more comfortable. Members of the Christian Science Church visit the home and patients regularly to provide spiritual support. Patients spoke positively about the meals provided at the home. Patients are provided with a menu, which contains a choice of meals. Patients can choose to eat in the dining room or privately in their own bedrooms. Care plans inspected include a reference to meals. The response generally indicated where the patient wished to take their meals. However one care plan did indicate the patient’s preference for a particular snack and drink. During a conversation with a patient the home was complimented on the selection and quality of vegetarian meals. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although patients know their complaints will be listened to and acted upon, the recording system does not ensure the registered manager has up to date information on patients’ concerns. Patients’ protection would be improved if all staff providing support and care to patients received appropriate Adult Protection training. EVIDENCE: During conversations with patients it was evident they knew of the action they would take if they had a complaint or concern. Details of the home’s complaint’s procedure are included in the service user guide, a copy of which is maintained in all patients’ bedrooms. A Regulation 26 report carried out and completed by the Company Secretary/Administrator for July 2006 indicated the home had received two unofficial complaints and the acting manager had handled the matters appropriately at that time. However the returned pre inspection questionnaire in support of this visit indicated the home had not received any complaints during the last twelve months. The registered manager completed the questionnaire. The registered manager was unaware of the two unofficial complaints. It was established on this visit that it has not been the home’s practice to maintain a central log of complaints or adverse comments. Having such a system would ensure the registered manager is fully aware of any matter requiring investigation and would assist her in monitoring trends for quality assurance purposes. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 15 Since the last visit arrangements have been made for staff to receive external adult abuse training. This is good practice and ensures staff know of the action to take if abuse is suspected in the home. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment is good, providing patients with an attractive, clean, comfortable and homely place to stay in. EVIDENCE: The home is kept well maintained both internally and externally. The standard of cleaning throughout the home is high and staff should be complimented on this. Patients commented on the extended lounge, which provides good views to the grounds surrounding the home. Following the completion of the lounge extension the home received its first fire safety inspection. This identified a number of matters, which did not fully meet the Workplace Fire Precautions Legislation. At this visit the Company Secretary/Administrator provided a copy Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 17 of a letter responding to the Fire Officer’s visit. This stated that all the requirements had been met. One matter, which is a recommendation, remains outstanding. However the home has submitted an alternative solution to the recommendation. The fire authority will consider this. The Company Secretary/Administrator agreed to keep the Commission informed of the outcome. An officer of the district council inspected the home’s kitchen and food store areas in January 2006. That visit found an excellent standard of food safety and awareness of food hygiene. The kitchen and practices were not re-inspected at this visit. Due to its rural location, security lights have been fitted externally as a safety measure to minimise risks to patients, visitors and staff. Since the last visit an additional aid to assist patients in moving and transferring has been acquired. Corridors are wide and enable patients to move independently around the home. All rooms used by patients are on the ground floor and are easily accessible. Patients are able to summon assistance with the aid of the call alarm system. Bedrooms visited varied in size and shape. Patients spoken with indicated their chairs and beds are comfortable. Patients are particularly appreciative of the adjustable beds, which they are able to activate themselves. Radiators seen in bedrooms are covered to prevent patients burning themselves. Thermostatic controls to adjust the radiator temperatures are fitted at a height, which enable patients to choose their own room temperatures. Indeed one patient described how they had done so the day before the visit because of the drop in temperature. Since the last visit thermostatic valves have been fitted to washbasins used by patients. This should ensure patients do not scald themselves. The home’s two laundry rooms are well equipped and ensure infection control risks are minimised. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff morale is good resulting in an enthusiastic workforce that works positively with patients to improve their whole quality of life. The vetting of staff must be further enhanced to minimise potential risks to patients. EVIDENCE: The home currently employs 13 Journal-listed Christian Science Nurses, and two student Christian Science nurses. In addition to these staff, staff are employed for administration, catering, housekeeping, activities and maintenance. Staff were seen interacting with patients in an unhurried manner. Indeed the atmosphere throughout the home during the visit was quiet and contemplative. Patients inferred this is the norm and helps them with their healing process. A record of staff on duty is maintained and demonstrates the home is staffed 24 hours a day. It has not been the home’s practice to include the status of staff on the duty rotas. This could present a problem if an investigation into poor care was carried out. A patient said they receive regular checks throughout the night and is comforted by this. New staff undergo thorough induction and foundation training. The programmes comply with Christian Science practice and principles, and Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 19 conform to National Training Organisation specifications. The Commission has agreed this. Two staff files were inspected. It was established that requisite vetting checks had been carried out to ensure staff fitness. However in one case the first employment was stated as 1999. Because of the employee’s age, this may not have been their first employment. There was no evidence the matter had been investigated. Regulations require full employment histories must be stated. Standard 28 was not assessed. Clarification is still awaited from the Commission on this standard. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally patients benefit from a well run home, but this could be further enhanced if roles and responsibilities between the registered manager and Company Secretary/Administrator were more clearly defined with particular regard to maintaining and availability of regulatory records. EVIDENCE: The registered manager is a Journal-listed Christian Science Nurse, has attained a requisite Registered Manager Award qualification and has worked at Charton Manor since 1995. During the last twelve months the registered manager has received Protection of Vulnerable Adults training and attended a Christian Science Association lecture/talk. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 21 The home has a current Certificate of Accreditation issued by The [Accrediting] Commission for Accreditation of Christian Science Nursing Organisations/Facilities. A new audit is due to be carried out by that Commission in 2007. Patients are requested to complete exit surveys on discharge, but the process is not proving very successful in that the home gets few responses. However the Company Secretary/Administrator undertakes monthly audits as part of his regulation 26 visits and makes a point of speaking to patients and staff to gather their views and opinions on the service. The registered manager also works a number of shifts on a “hands on” basis. This enables her to have more time with individual patients. Formal supervision of staff is now rolling out and records are maintained of points discussed. The returned pre inspection questionnaire included details of policies and procedures. However there was some evidence that not all of these are being regularly reviewed. Indeed some policies had implementation or reviews dates of 1999, 2001, 2002 and 2003. This situation may prevent staff working in accordance with current good practice and indeed current legislation. As stated previously, the home does not centrally log complaints and adverse comments. This may prevent the home analysing trends to see if any changes or improvements to the service are needed. Appropriate systems are now in place for recording and maintaining personal monies and or important items on patients’ behalf. Four members of staff are trained to provide first aid treatment to nonChristian Science staff and visitors. A first aid box is kept for this purpose and records are kept to ensure it is regularly inspected to check on the contents. The pre inspection questionnaire indicates that the home’s equipment is maintained and serviced. Records are now kept of hot water temperatures obtained from the patients’ ensuite showers. There was some confusion as to the whereabouts of completed accident forms. A blank accident book is kept at the nurses’ station, but it could not be ascertained whether this was for staff, patients, the nursing home or the associated domiciliary care service. The situation is compounded in that the registered manager does not see the completed forms because they are passed to the Company Secretary/Administrator for processing. This situation may prevent the registered manager having a proper insight into events happening in the home. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 N/A 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19(1)(b) sch 2, para 6 Requirement The registered person shall not employ a person to work at the care home unless subject to paragraph 6 he has obtained in respect of that person the information and documents specified in schedule 2, including a full employment history, together with a satisfactory written explanation of any gaps in employments. Timescale for action 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP16 Good Practice Recommendations The current method of inviting patients to be involved in the composition of their care plan should be reviewed. A central complaints logging system should be devised and made accessible to the registered manager. Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 24 3 4 OP18 OP19 Adult Protection training must be extended to all members of staff involved in delivering care and support to patients. The Commission should be provided with a copy of the Fire Safety Officer’s response to the provider’s alternative solution to the outstanding fire safety recommendation. The Commission should be provided with a copy of the building completion certificate in respect of the lounge extension. Staff rotas should contain the status of the staff on duty for ease of auditing. Policies and procedures should be regularly reviewed and updated to ensure they comply with current good practice and legislation. The system of maintaining completed accident report records should be reviewed to ensure the registered manager is fully aware of current trends. 5 OP19 6 7 OP27 OP33 9 OP38 Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Charton Manor DS0000040103.V315267.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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