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Inspection on 23/05/06 for Chataway Residential Home

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

This inspection was carried out on 23rd May 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.

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

Communication between residents, their relatives and the staff in the home, remain good. The manager has succeeded in arranging more frequent resident and relative meetings building on the quality assurance in the home. Elements of care are inclusive of good practice, with all care plans having been re-written, and long-term residents having their needs re-assessed. The information gathered in the assessment process is more objective. The medication process is secure, with no errors or omissions in the process. The home is clean and hygienic, with staff having protective clothing available, enabling protection of residents in the home. Staff training is assessed through the annual appraisal basis and staff supervision is in place. The manager communicates appropriately with official bodies such as the Environmental Health Officer, Fire Officer and the Commission for Social Care Inspection. All pre-employment documentation is now in place prior to staff commencing employment.

What has improved since the last inspection?

All of the requirements and recommendations from the last inspection in October 2005 have now been actioned. The provision of fresh fruit, vegetables and meat has been added to the menu choices. The policies and procedures in the home could be reviewed and updated with the current registered persons details included in all appropriate documents;

What the care home could do better:

Though the staffing numbers have been reviewed, these could still be revisited and staff appointed to times of the day to increase the security for this frail elderly group, and to assist at meal times.

CARE HOMES FOR OLDER PEOPLE Chataway Residential Home 4 East Avenue Whetstone Leicestershire LE8 6JG Lead Inspector Keith Williamson Unannounced Inspection 23rd May 2006 09:00 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 DS0000061583.V296570.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. DS0000061583.V296570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chataway Residential Home Address 4 East Avenue Whetstone Leicestershire LE8 6JG 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) 0116 2848306 0116 2848306 Clearvision (GB) Limited Mrs Elaine Hiles Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Physical disability over 65 years of age (3) of places DS0000061583.V296570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling within category PD (E) may be received into the home when there are already 3 persons of category PD (E) accommodated in the home. 3rd October 2005 Date of last inspection 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. DS0000061583.V296570.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection took place over one day, commenced at 9.00 am and was completed in six and one half hours by one Inspector. An opportunity was taken to view the care plans and other records in detail. Four residents were spoken with on this visit; comments made are enclosed within this report. The manager and deputy manager assisted in the inspection process. The current fees charged are £319 to £379 per week. What the service does well: What has improved since the last inspection? All of the requirements and recommendations from the last inspection in October 2005 have now been actioned. The provision of fresh fruit, vegetables and meat has been added to the menu choices. DS0000061583.V296570.R01.S.doc Version 5.2 Page 6 The policies and procedures in the home could be reviewed and updated with the current registered persons details included in all appropriate documents; 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. DS0000061583.V296570.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 DS0000061583.V296570.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is followed consistently for all planned admissions. EVIDENCE: The home does not currently offer a service under Standard 6, intermediate care. Pre admission assessments are used by the home for all admissions. The manager has completed re-assessing the longer-term residents in the home. All service user files seen on the day included a contract, which had the appropriate information enclosed to protect residents residency in the home. DS0000061583.V296570.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well looked after in respect of their health and personal care needs. EVIDENCE: Individual resident care plans are in place, these are detailed on a personal basis and are under regular review. The manager and deputy have now rewritten all of the care plans in the home, ensuring all staff have the appropriate information to care for residents in the home. Residents and their relatives continue to have the choice of being included in the care planning process, though none of the care plans viewed had been signed by a resident or their relative. A number of files demonstrated intervention by health care professionals. A record of important communications to residents relatives is also made, to ensure vital health or other issues are communicated appropriately. DS0000061583.V296570.R01.S.doc Version 5.2 Page 10 The medication system is well managed with a sample check of the system indicating all information on dispensing and returning medication to the pharmacy is accurate. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. They were observed speaking with residents in a respectful, friendly and supportive way. Residents spoken with said confirmed that staff are respectful and very caring. The home organises information in the plan of care, with regard to the final wishes of residents, this is good practice as the information is at hand at this emotive time. One resident commented about the staff, “ x was very nice, they accompanied me to hospital”, and went on to state “they’ve catered for my needs very well”. DS0000061583.V296570.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Regular in house entertainment is organised with residents having a choice of “music and mobility” sessions, group activities within the home, and occasional trips out for pub meals, with relatives being included in this process. The meal served on the day of the inspection was braised steak, fresh potatoes and vegetables were also on offer, a vegetarian option was also offered, the meal was served in a relaxed atmosphere and was well portioned and positioned on the plate. Evidence is in place of special diets being catered for, with a resident stating “they cater for my (dietary) needs very well”, another commented the food was “passable”. One resident commented “I enjoy the keep fit and occasional sing-song” another commented “I prefer my daily paper”. DS0000061583.V296570.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are now protected from abuse by having the appropriate information to hand. EVIDENCE: The home has had one concern reported to the commission for social care inspection since the last inspection; this was appropriately investigated and acted on by the Registered Provider. The home has the necessary complaints procedure and policies in place. Staff spoken with have a good awareness of the policy content and how the procedure was operated. Residents spoken with were also aware how to make complaints, one stating, “I would speak to the Manager, she speaks to us all every day”. The Complaints Record was viewed, which evidenced that the home has received complaints since the last inspection; the outcome of the complaints was recorded along with any action necessary. Detailed examination of the adult protection policy indicated that sufficient information is contained in the document for staff members’ guidance on how to prevent elder abuse in the home. Information on the complaints procedure and Protection of Vulnerable Adults policy (pova) have been circulated to residents and their relatives. DS0000061583.V296570.R01.S.doc Version 5.2 Page 13 Staff members spoken to displayed good verbal knowledge concerning the protection of vulnerable adults in their care, indicating that they occasionally read the adult protection policy to keep their knowledge of adult protection updated. DS0000061583.V296570.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 19, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable and clean standard of accommodation is provided for service users. EVIDENCE: Service users spoke positively of their environment. A comfortable and clean standard of accommodation is provided for service users. Two bedrooms were viewed by the inspector were found to be in good decorative order, and furnished to meet the needs of the individual, including provision of furniture and personal items provided by the resident. A programme of maintenance is in place with planned work due to commence on the re-decoration of the corridors in the home shortly. Equipment is available to assist service users and staff in the delivery of personal care, which includes assisted baths, moving and handling equipment DS0000061583.V296570.R01.S.doc Version 5.2 Page 15 including hoists. Staff have had recent training on infection control and Control of Substances Hazardous to Health (COSHH). DS0000061583.V296570.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and training programmes now protect residents in the home. EVIDENCE: The staffing rota was examined and a physical count indicated that there was adequate numbers of care staff on duty. The staffing rota was viewed and discussion held with the manager indicated that there is appropriate skill mix of staff employed to work in the home. Residents’ spoken with indicated that there are staff members available when needed. A comment passed by a resident indicated, “(the staff) there like our family”. A range of training is available to staff, this is ascertained after an annual appraisal and takes the needs of the current resident group into account. The Inspector viewed a selection of staff recruitment records, all the necessary employment checks, which included written references and a Criminal Record Bureau check, were in place. DS0000061583.V296570.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach promotes effective care practice in the home for residents’ care and protection. EVIDENCE: The current acting manager is qualified to run a residential care home, gaining her National Vocational Qualification level 4 award. The manager continues to have a strong reliance toward a quality assurance framework; with resident meetings attended by relatives on a bi-monthly basis. No resident’s monies are currently held within the establishment, with all resident bedrooms viewed having the appropriate locking facilities. DS0000061583.V296570.R01.S.doc Version 5.2 Page 18 Staff supervision has now commenced; this was confirmed by the staff in the home. Records kept to ensure the safety of residents in the home, have been reviewed and are up to date. DS0000061583.V296570.R01.S.doc Version 5.2 Page 19 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 DS0000061583.V296570.R01.S.doc Version 5.2 Page 20 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000061583.V296570.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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 DS0000061583.V296570.R01.S.doc Version 5.2 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!