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Inspection on 21/05/05 for Chataway Residential Home

Also see our care home review for Chataway Residential Home for more information

This inspection was carried out on 21st May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Elements of care point toward good practice and a good rapport with a number of Residents and their relatives in the home, with comments forwarded being very positive "I think the care is excellent", "the staff are very caring", "the food is of a very high quality", "when I visit my mother is always very clean and well cared for". The catering is considered by many residents and their relatives to be of "a very high standard".

What has improved since the last inspection?

It is not possible to comment on improvements in the home on this occasion.

What the care home could do better:

The information provided in the admission and assessment process prior to Residents moving in to the home could be expanded. Care planning could be more concise and broadened to take in a holistic approach to Residents needs; daily records could again be improved with more concise information. Staffs` approach and communication with residents could be improved. The information and training of staff over the issue of moving and handling could be improved. Staff induction could be broadened to include a set instruction process, and training in general should be less of a "cascade system" as this is to reliant on the staff instructing other staff.

CARE HOMES FOR OLDER PEOPLE Chataway 4 East Avenue Whetstone Leicestershire LE8 6JG Lead Inspector Keith Williamson Unannounced 21 May 2005 at 9.00am 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 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. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chataway Address 4 East Avenue Whetstone Leicestershire LE4 6SN 0116 2848306 0116 2863513 None Clearvision (GB) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr. Rajani Care Home 14 Category(ies) of OP Older Persons - 14 registration, with number PD(E) Physical Disability over 65 years - 3 of places Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No one falling within category PD E may be received into the home when there are already 3 persons of category PD E accommodated within the home. Date of last inspection 30/11/04 Brief Description of the Service: Chataway Residential Home is situated on a small cul-de-sac, close to the centre of Whetstone, and provides accommodation for up to fourteen older persons. The home is an extended detached house. Accommodation is on two floors; access to the first floor is via stairs or stair lift. There is a large lounge/dining room and conservatory. The home has a small but pleasant courtyard and garden area to the rear of the property leading from the conservatory. The home has both single and shared rooms, some with ensuite facilities. The home is situated close to some local shops, and is serviced by a bus route to the city Leicester. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 days commencing at 8.00 am on day one and 9.00am on the second day, and was prompted following a complaint to the Inspector. The Inspector interviewed residents their relatives and staff in the process, and both the owner and acting manager assisted with the inspection. The Inspector took a chance to look at policies and procedures and look at care files and other documents in the office. It is important to bear in mind that this is the first Inspection of the recently appointed owner, and acting manager therefore it is difficult to define what the home does well due to the nature of the inspection. There is a clear designation in the home between the previous and current management approach and this has clearly had an effect on the type of Residents admitted, paperwork and its review, staff and staffing within the home. There has been a recent turnover in the staff group with a number of care staff leaving the home, it was apparent the replacement staff shall take time to build up the relationship with the Residents and their relatives in the home, the management emphasis should be directed in assisting that process. What the service does well: What has improved since the last inspection? It is not possible to comment on improvements in the home on this occasion. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 6 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. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 6. Residents are not protected by the assessments that are completed prior to admission to the home. EVIDENCE: Contracts were not seen in all files viewed; the type issued is dependant if the Resident is privately or Social Service funded. Assessments were viewed for a sample of Residents in the home. These were reflective of some Residents needs, however the needs assessed for one Resident indicated the home should not have admitted that Resident with those particular needs, as these were outside the registration categories of the home. The home does not provide a service for Standard 6 (intermediate care). Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 10. Residents are not looked after in respect of their health, personal care and medication needs. Residents’ rights to privacy and dignity are not upheld. EVIDENCE: Individual plans of care are in place, and to a point are descriptive but are not followed by staff in providing care for residents in the home. Risk assessments were seen and are used in conjunction with care plans, however are not complete and omit to recognise major health issues such as diabetes. Continence wear prescribed for specific Residents are “borrowed” for other Residents, this practice must cease and all Residents be prescribed their own, following an appropriate assessment from a continence professional. The Inspector found a number of out-of-date medication items were required to be disposed off; these were not done at the time. A controlled medication was not stored appropriately, stock levels were incorrect and general administration was poor. Staff were witnessed by the Inspector, overriding the issues of a Resident s’ dignity, and were witnessed assisting one male Resident out of bed, with the bedroom door propped open. Another member of staff continually talked “above” a Resident who was being transported in a wheelchair. A large Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 10 amount of (confidential) written material is on public display to the ground floor of the building. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15. Giving residents’ choices over their daily lifestyles and providing a wellbalanced meal is managed very well for residents in the home. EVIDENCE: Of the Residents relatives interviewed on the day, confirmation was obtained with regard to the social care on offer to the group. A variety of entertainment is offered and meets the needs of the group. Conflicting statements were forwarded such as, “mum is stimulated here” and “mum sits next to the t.v. all day, its very loud”. The meal provision is assisted by two cooks being employed, one specifically for breakfasts the other for lunches and teas; the menu offers a balanced diet and choice for Residents Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Residents are not protected by having information about the complaints procedure. EVIDENCE: Though a complaints policy and procedure exists, no way of recording complaints exists in the home. One relative of a recently admitted resident stated, they had not been told there was a complaints policy, not been given any such information at the point of their relatives admission, and was unaware of its existence. It is recommended that the complaints policy, is forwarded to all residents relatives with information regarding the use of the policy. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) none No environmental inspection was carried out on this occasion. EVIDENCE: Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. The recruitment procedures and training programmes do not protect residents. EVIDENCE: The current owner stated he has introduced individual staff files, however these are incomplete with some of the pre employment paperwork missing or incomplete. There is no proof that specific designations of staff are appropriately trained to complete the tasks set for them, for instance domestic staff with no Health and Safety training. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37 & 38. Residents are not protected as there is an inconsistent approach to Heath and Safety in the home. EVIDENCE: There were a number of health and safety issues with regard to staff training and provision of equipment that lead the Inspector to believe staff are not fully aware of their obligations under this legislation. A number of staff have completed Health and Safety training in the home, though not recently and this is required to be updated; interpretation of the training is also somewhat in question, with care staff openly admitting to “lifting” residents and cleaning staffs’ complacency over trailing sockets, and generally over the availability of moving and handling equipment. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x 2 2 2 Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 17(2) Requirement The Responsible Individual must ensure all Residents are issued with a statement of terms and conditions. The Responsible Individual must ensure that all Resident Assessments are completed prior to moving into the home, and then re completed periodically to ensure they reflect the current needs and abilities of Residents in the home. The Responsible Individual must ensure that Resident Care Plans are, individualised, detailed and encompass all areas of ability and need. The Responsible Individual must ensure that care plans are regularly reviewed to ensure they reflect the residents’ current abilities and needs. The Responsible Individual must ensure that all residents care plans include the appropriate risk assessments. This was an Immediate Requirement at the last inspection The Responsible Individual must ensure that regular weight and Timescale for action 1st August 2005. Immediatel y 2. 3 14 (1,2) 3. 7 15(2) 1st August 2005. 4. 7 15(2) Immediatel y. 5. 7 15(2) Immediatel y. 6. 8 17(1) 1st August 2005. Page 18 Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 7. 9 13(2) 8. 10 12(4) 9. 16 22 10. 27 18(1) 11. 29 17(2) 12. 30 18(1) nutrition information is kept as part of the recording system, and available for residents in the home, and is available for future inspections. The Responsible Individual must ensure that all medications are administered appropriately, and no sub dispensing of medication happens in the home. The Responsible Individual must ensure that Residents privacy and dignity is ensured and staff instructed accordingly. The Registered Person must operate an appropriate complaints procedure and ensures all complaints are recorded and acted on appropriately. The Responsible Individual must ensure that the staffing numbers reflects the residents’ needs, and an accurate staffing rota is maintained at all times in the home. The Responsible Individual must ensure that all staff must have the appropriate documentation prior to commencing employment in the home, (as per Schedule 4). The Responsible Individual must ensure that all staff have an individual training programme to reflect their individual needs, this must include the recognised “statutory” training. This must also reflect the residents care needs. The Responsible Individual must ensure that all staff must have the appropriate induction and foundation training. The Responsible Individual must ensure that all staff must be appropriately supervised as part Immediatel y Immediatel y Immediatel y Immediatel y Immediatel y 13. 30 18(1) the plan to be in place by 24th July 2005 and training commence d by 24th August 2005. Immediatel y commence d by 17th July 2005. Page 19 14. 36 18(1) Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 15. 37 12(1) 16. 37 12(1) 17. 37 12(1) 18. 37 12(1) 19. 38 18(1) of staff development, that is then recorded and made available at future inspections. The Responsible Individual must ensure that all accidents and incidents are recorded and reported on to the appropriate authorities. The Responsible Individual must ensure that all Moving and Handling equipment is appropriately serviced, and provided for staff to meet the individual needs of residents in the home. The Responsible Individual must ensure that all Residents in the home have an appropriate moving and handling assessment in place, performed by a person qualified and experienced to do so. The Responsible Individual must ensure that the Hoist in the home is serviced at appropriate intervals. The Responsible Individual must ensure that all staff are aware of their responsibilities under the Health and Safety Act and Manual Handling Regulations. Immediatel y Immediatel y by 1st September 2005. 17th July 2005 Immediatel y 20. 21. 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 2 7 Good Practice Recommendations It is recommended that the Registered Person ensures that the bedroom numbers are entered on the Residents contract (or Individual Placement Agreement). It is recommended that the Registered Person ensures that C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 20 Chataway 3. 4. 5. 11 16 18 6. 7. 8. 9. 18 32 36 37 time be set aside for staff to read the care plans and make themselves familiar with residents personal needs. It is recommended that the final wishes of Residents are ascertained sensitively and entered in the plan of care. It is recommended that the Registered Person reviews and re-issues the complaints procedure to all Residents and their representatives. It is recommended that the Registered Person obtain a copy of the guidance for referral and process for referring an individual to Secretary of State for inclusion onto the Protection Of Vulnerable Adults register. It is recommended that the Registered Person ensures that staff are appropriately instructed on the Protection Of Vulnerable Adults policy. It is strongly recommended that the Registered Person obtains a copy of the National Minimum Standards, and enlightens staff with the innformation therein. It is recommended that the Registered Manager ensures that staff records of supervision include areas of staff performance, including areas of concern. It is recommended that the Registered Person reviews all policies in the home. Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 21 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chataway C51 S61583 Chataway V228236 210505.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!