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Inspection on 26/07/05 for Chataway Residential Home

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

This inspection was carried out on 26th July 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

This remains as at the last inspection. Elements of care point toward good practice and a good rapport with a number of Residents and their relatives in the home, with comment cards being forwarded to the inspector prior to the last inspection, 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?

The assessments completed prior to residents moving in to the home, have improved with a profile being obtained, and subsequent care plan then compiled. Training programmes have commenced for the staff, and induction training is in the process of commencing for the newly appointed staff in the home. Matters such as residents` privacy and dignity; how complaints are dealt with and recorded by staff, and how accidents are recorded, have been raised at a recent staff meeting.

What the care home could do better:

Residents` contracts have not yet been re-issued with the appropriate information, and no residents have yet been re-assessed. Care plans have not yet been re-written with the appropriate details on individual resident abilities, and do not give a balanced view of how to care for residents in the home. Risk assessments were required to be added to the residents` files, immediately after both the last and previous inspections, this work has not been commenced. Individual weight and nutrition information has not yet been gathered or added to the recording by care staff. Medication administration is still causing concern with the accounting and double signing of a "controlled" medication being the cause of some concern. The rota was viewed and staffing is still an issue as 2 care staff are employed on each "shift", however for over 2 weeks one member of care staff has had to prepare and serve lunches, this situation must be rectified and an appropriate amount of staff be employed to cope with the care and associated needs of residents in the home. New staff employed in the home still do not have the satisfactory pre employment checks in place. The responsible person stated staff supervision has commenced but no records of these sessions exist. The routine servicing of moving and handling equipment is the subject of some concern, as the responsible person is unaware of the recommended service intervals; moving and handling assessments have not yet been put in place.

CARE HOMES FOR OLDER PEOPLE Chataway Residential Home 4 East Avenue Whetstone Leicestershire LE8 6JG Lead Inspector Mr Keith Williamson Unannounced 26 July, 2005 09:00 am th 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 Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chataway Residential Home Address 4 East Avenue Whetstone Leicestershire LE8 6JG 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) Vacant Care Home (CRH) 14 Category(ies) of Old age, not falling within any other category registration, with number (OP) 14 both, Physical disability over 65 years of of places age (PD(E)) 3 both. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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 21/05/05 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 Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 1 day commencing at 9.30 am and lasted three and a half hours; and was a follow up inspection following a complaint to the Inspector. The Inspector interviewed the Responsible Person and staff in the process. The Inspector took note of any changes to policies and procedures and look at care files and other documents in the office. This is the second Inspection of this service and concentrates on the requirements and recommendations from the first visit in May 2005. At the last inspection there were 19 requirements and 9 recommendations, of which 16 requirements are still outstanding. Overall this is a poor report with a lack of guidance from the inexperienced responsible person being an inherent factor in the homes under achievement; an experienced manager could bring the guidance the home requires to redress the balance of consistently poor practice in the home. The home continues to have a good relationship with the majority of residents and their relatives, with no complaints being forwarded to the CSCI. What the service does well: What has improved since the last inspection? The assessments completed prior to residents moving in to the home, have improved with a profile being obtained, and subsequent care plan then compiled. Training programmes have commenced for the staff, and induction training is in the process of commencing for the newly appointed staff in the home. Matters such as residents’ privacy and dignity; how complaints are dealt with and recorded by staff, and how accidents are recorded, have been raised at a recent staff meeting. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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 Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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 Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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. Residents are still not protected by the admission procedures apparent in the home. EVIDENCE: Resident files were viewed, to ascertain if contracts had been revised, these have been, but still do not contain the appropriate information required by the National Minimum Standards. Assessments were viewed for a sample of residents in the home; on this occasion the inspector witnessed an assessment appropriately filled in prior to the residents’ admission to the home, however no attempt has been made to review the longer term residents’. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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) Residents are still not looked after in respect of their health, personal care and medication needs. Residents’ rights to privacy and dignity are now recognised in the home. EVIDENCE: Individual plans of care remain in place, though still do not recognise resident’s individual abilities and needs. Risk assessments are used in conjunction with care plans, however are not complete and still fail to recognise major health issues such as diabetes. No evidence was seen of the staff having commenced records of residents weight or nutritional input. The issue of risk assessments has been an immediate requirement for the past two inspections; residents’ health, safety and welfare is being compromised by the continued failure by the responsible person to complete these. The medication is now administered in a more professional and secure way, with the medication cabinet’s being moved to a less public area; however the controlled medication is still not being stored appropriately, stock levels were Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 10 inconsistent with the signatures, and some signatures were missing; therefore general administration of the medication system is poor. The confidential written material, which was on public display in the ground floor of the building, has now been removed. Residents right to privacy and how that can be achieved and promoted in the home, has been openly discussed at staff meetings minutes of which were seen on this visit. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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) None No standards were viewed on this occasion. EVIDENCE: Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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 & 18 Residents are now protected by having information about the complaints procedure. EVIDENCE: The responsible person stated all residents and their families had been issued with a copy of the complaints procedure and a complaints form. This process also included staff being given information on how to collect and process complaints and protection of vulnerable adult information. This is seen as a positive move by the inspector and the staff congratulated with the efforts in this area. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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 standards were viewed on this occasion. EVIDENCE: Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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 still do not protect residents. EVIDENCE: The responsible person continues to employ staff with the pre employment paperwork missing and files being incomplete. Some work has been done with induction training for staff in the home, that shall lend toward and overall training package for the staff, the content of this training was discussed between the responsible person and the inspector. Individual training plans have commenced; it is up to the delegated member of staff to ensure these are kept up-to-date. It was noted during this inspection that the amount of staff available to perform care tasks was not considered appropriate for the dependencies within the resident group at that time, on investigation these staffing levels had been apparent for more than 2 weeks. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 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) 32, 36, 37 & 38. Residents remain at risk, as there remains an inconsistent approach to Health and Safety in the home. EVIDENCE: 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, and this was discussed at length by the responsible person and inspector. There is evidence of health and safety issues being discussed at a staff meeting, this commences the process of educating the staff in this area, however formal training has still to be arranged, and this must be seen as a priority by the responsible person in the home as the staff are still not fully aware of their obligations under this legislation. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 16 Formal recorded staff supervision has not yet commenced, this when started could ensure staff are have the appropriate development for resident care plans and training within the home . No acting manager has yet been appointed in post, this situation is untenable, as the current responsible person does not have the skills to enable the home to function in a safe way for residents and staff alike. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 17 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 2 x x x 2 2 2 Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 original timescale of the 1st August has not been met. The Responsible Individual must ensure that all resident assessments are re-completed periodically to ensure they reflect the current needs and abilities of residents in the home. The original immediate timescale has not been met. The Responsible Individual must ensure that Resident Care Plans are, individualised, detailed and encompass all areas of ability and need. The original timescale of the 1st August has not been met. The Responsible Individual must ensure that care plans are regularly reviewed to ensure they reflect the residents’ current abilities and needs.The original immediate timescale has not been met. The Responsible Individual must ensure that all residents care plans include the appropriate risk Timescale for action 6th September 2005. 2. 3 14(1 & 2) 26th July 2005. 3. 7 15(2) 6th September 2005. 4. 7 15(2) 26th July 2005. 5. 7 15(2) 26th July 2005. Page 19 Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 6. 8 17(1) 7. 9 13(2) 8. 27 18(1) 9. 29 17(2) 10. 36 18(1) 11. 37 12(1) assessments. This was an Immediate Requirement at the last two inspections. The Responsible Individual must ensure that regular weight and nutrition information is kept as part of the recording system, and available for residents in the home, and is available for future inspections. The original timescale of the 1st August has not been met. The Responsible Individual must ensure that all medications are administered appropriately, and no sub dispensing of medication happens in the home. The original immediate timescale has not been met. 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 original immediate timescale has not been met. 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 original immidiate timescale has not been met. The Responsible Individual must ensure that all staff must be appropriately supervised as part of staff development, that is then recorded and made available at future inspections. The original timescale of the 17th July has not been met. The Responsible Individual must ensure that all accidents and incidents are recorded and reported on to the appropriate 6th September 2005. 26th July 2005. 26th July 2005. 26th July 2005. 6th September 2005. 26th July 2005. Chataway Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 20 12. 37 12(1) 13. 37 12(1) 14. 38 18(1) 15. 38 18(1) authorities. The original immediate timescale has not been met. 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 original immediate timescale has not been met. 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 all staff are aware of their responsibilities under the Health and Safety Act and Manual Handling Regulations. The original immediate timescale has not been met. The Responsible Individual must ensure that all incidents and occurences under the heading of Regulation 37, are forwarded to the CSCI immediately after the event. 26th July 2005. by 1st September 2005. 26th July 2005. 26th July 2005. 16. 17. 18. 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. Refer to Standard 2 Good Practice Recommendations It is recommended that the Registered Person ensures that the bedroom numbers are entered on the Residents D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 21 Chataway Residential Home 2. 3. 4. 7 11 18 5. 6. 18 32 7. 8. 36 37 contract (or Individual Placement Agreement). It is recommended that the Registered Person ensures that 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 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 third edition or later if available, and enlightens staff with the information 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 Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 22 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 Residential Home D C51 C01 S61583 Chataway V240661 260705 Stage 4.doc Version 1.40 Page 23 - 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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