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Inspection on 03/10/05 for Chataway Residential Home

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

This inspection was carried out on 3rd October 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

Communication between residents, their relatives and the staff in the home, remain good, the acting manager attempting to enhance these further by arranging more frequent meetings. Elements of care point toward good practice and a good rapport with a number of residents and their relatives in the home, with recent 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 home is clean and hygienic, with staff having the appropriate protective clothing available enabling protection of residents in the home.

What has improved since the last inspection?

The information gathered in the assessment process is more objective. Care planning is more concise and takes a holistic approach to residents needs; daily records have been improved and are kept with the plans of care. Staff are being encouraged to read the plans of care on a regular basis. The information and training of staff on moving and handling has been improved with further training arranged; the moving and handling equipment has been upgraded and is now stored centrally in the home for ease of availability for all staff. Many of the requirements and recommendations from the last inspection in May 2005, had not been actioned by the commencement of this inspection on the 3rd October 2005, but with the commencement of the manager that same day, a number had been completed by the commencement of the second day of the inspection. All residents or their relatives have been issued with revised terms and conditions of their stay, and the appropriate information on bedroom numbers is recorded in contracts. Risk assessments have been added to plans of care, which also now contain nutritional and weight information. Medication is now administered appropriately, further training has been arranged and undertaken by a number of care staff, and the acting manager is monitoring the whole process. Medication storage has been moved to a more secure area of the building. Staff supervision has commenced, this process also recognises ongoing staff development and training. Accidents and incidents are now being recorded appropriately and warning notices are being sent to the appropriate authorities. Training has been offered to the staff on the Protection of Vulnerable Adults policy (pova), and Moving and Handling, with more equipment being bought and stored centrally in the home.

What the care home could do better:

Though the staffing numbers have been reviewed, and an extra member of staff employed in an evening; these could be revisited and staff appointed to other times of the day to increase the security for this frail elderly group, and to assist at meal times. The provision of fresh fruit, vegetables and meat could be added to the menu choices. All pre-employment documentation could be in place prior to staff commencing in post, this again would increase the security and protection of this group of residents. The policies and procedures in the home could be reviewed and updated with the current registered persons details included in all appropriate documents; the complaints procedure could be updated to include the appropriate contact details of the commission for social care inspection.

CARE HOMES FOR OLDER PEOPLE Chataway Residential Home 4 East Avenue Whetstone Leicestershire LE8 6JG Lead Inspector Keith Williamson Unannounced Inspection 3rd October 2005 09:30 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 Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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 Clearvision (GB) Limited Mr Satbinder Gill 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 Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. Mr N Rajani registered as the Responsible Individual submit an application for a Registered Manager within two months of registration of the company. 21/05/05 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 en-suite facilities. The home is situated close to some local shops, and is serviced by a bus route to the city Leicester. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 days commencing at 9.30 am on both days. The Inspector interviewed residents and staff in the process, and the registered person assisted on both days, the acting manager assisting on day 2 only. The Inspector took a chance to look at policies and procedures and look at care files and other documents in the office. This is the second Inspection of the owner, and the first of the acting manager. There was a clear indication within the inspection process of the dramatic improvements made from the time the new manager commenced. What the service does well: What has improved since the last inspection? The information gathered in the assessment process is more objective. Care planning is more concise and takes a holistic approach to residents needs; daily records have been improved and are kept with the plans of care. Staff are being encouraged to read the plans of care on a regular basis. The information and training of staff on moving and handling has been improved with further training arranged; the moving and handling equipment has been upgraded and is now stored centrally in the home for ease of availability for all staff. Many of the requirements and recommendations from the last inspection in May 2005, had not been actioned by the commencement of this inspection on the 3rd October 2005, but with the commencement of the manager that same day, a number had been completed by the commencement of the second day of the inspection. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 6 All residents or their relatives have been issued with revised terms and conditions of their stay, and the appropriate information on bedroom numbers is recorded in contracts. Risk assessments have been added to plans of care, which also now contain nutritional and weight information. Medication is now administered appropriately, further training has been arranged and undertaken by a number of care staff, and the acting manager is monitoring the whole process. Medication storage has been moved to a more secure area of the building. Staff supervision has commenced, this process also recognises ongoing staff development and training. Accidents and incidents are now being recorded appropriately and warning notices are being sent to the appropriate authorities. Training has been offered to the staff on the Protection of Vulnerable Adults policy (pova), and Moving and Handling, with more equipment being bought and stored centrally in the home. 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 DS0000061583.V254858.R01.S.doc Version 5.0 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 Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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): 1, 2, 3 & 5. Residents are now protected by the pre-admission documents completed prior to admission to the home. EVIDENCE: Evidence is in place of the recently introduced of pre-admission assessments completed by the manager, these are then used appropriately to form the individual plan of care. The Statement of Purpose and Service User Guide have yet to be completed with the new owners details. Residents’ contracts now have confirmation of the bedroom allocated for the duration of the residents stay. Residents are openly welcomed to view the home prior to moving in. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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. Residents are now looked after in respect of their health, personal care and medication needs. EVIDENCE: Recently admitted residents care plans have now began to be produced in such a way that recognises residents’ individual abilities, the acting manager has started to alter other residents plans of care to reflect the same positive areas of care. The new style plans include areas to cover residents’ health and nutritional needs, and records specific intervention by health care professionals. The security surrounding the medication administration process has been increased, and the inspector recognises the recent work done by the acting manager in supervising the running of the system. Staff training has commenced in areas of medication administration and a delegated nursing task. Evidence is also in place of staff instruction on how to rightfully respect individual residents privacy and dignity. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 10 Residents final wishes have been entered in the plans of care of recently admitted residents, and the acting manager has indicated how this shall be introduced in a sensitive manor for longer-term residents. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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): 14. Residents are provided with appropriate choices within the home. EVIDENCE: Residents have appropriate choices in the home, these include meals, times of going to bed and rising, choice of clothing and times of bathing. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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. Residents are not protected from abuse by having the appropriate information to hand. EVIDENCE: The registered person has not supplied residents or their relatives with the appropriately updated information to enable complaints to be brought to the notice of the current management or the commission for social care inspection. Staff have began to have information and training regarding the adult protection policies and procedures (pova). Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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 the following standard(s): 19 & 26. Residents are protected by a well maintained and hygienic environment. EVIDENCE: The fabric and décor within the home are well maintained, though there is no specific programme in place to indicate timescales on outstanding work awaiting completion. The environment of the home is hygienic, with no odours present; staff are aware of issues surrounding cross infection and cross contamination, and take appropriate action to ensure the safety of themselves and residents in the home. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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 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, 29 & 30. The recruitment procedures and training programmes do not protect residents. EVIDENCE: The Registered Person has introduced individual staff files, however these continue to be incomplete even for new staff commencing employment since the last inspection. There has been little improvement on ensuring that staff have the appropriate training in place to increase resident safety in the home; the requirements in the last report are now being acted on by the acting manager, but the delay in introducing these basic observations are unacceptable. There has been a recent review of staffing and the evening staff numbers increased by one person; the acting manager indicated she is continuing to review the residents’ dependency levels and shall ensure the appropriate staffing numbers accordingly. The acting manager is now arranging an increased staff training programme; this is linked to individual staff abilities. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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 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, 37 & 38. The management and administration in the home is being managed and now ensures resident safety. EVIDENCE: The current acting manager is qualified to run a residential care home, and has commenced organising the introduction of a quality assurance framework; this is admirable considering the short period of time she has been employed in the home. No resident’s monies are currently held within the establishment. Staff supervision has now commenced, though in the early days of the programme the current acting manager has a clear view as to the content and use of this within the staff group. Records kept to ensure the safety of residents in the home, are being reviewed, some have been brought up to date, though further work is necessary to ensure resident safety. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 16 The current staff group are midway through a training refresher on health and safety; the acting manager has introduced a number of risk assessments on completing a review of resident abilities within the home. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 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 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 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 3 X 3 X 3 3 3 3 Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 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 OP16 Regulation 22 Requirement The Registered Person must operate an appropriate complaints procedure and ensures all complaints are recorded and acted on appropriately. The Registered Person must make all staff aware of the Protection of Vulnerable Adults policy (pova) policies and procedures. The Registered Person must ensure the protection of residents at all times. The Registered Person must ensure that all staff must have the appropriate documentation prior to commencing employment in the home, (as per Schedule 2). The original immediate timescale has not been met. Timescale for action 14/11/05 2 OP18 12 & 19 14/11/05 3 4 OP27 OP29 18 19 17/10/05 17/10/05 Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 19 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 3 4 5 6 Refer to Standard OP9 OP15 OP15 OP19 OP27 OP30 Good Practice Recommendations It is recommended that all staff administering medication are offered accredited medication training. It is recommended that the menu for meals be displayed prominently in the home for residents and their relatives information. It is recommended the menu for the residents is made up in advance, is balanced nutritionally and includes fresh vegetables, fruit and fresh meat and meat products. It is recommended that timescales be added to the plan of maintenance for the home. It is recommended that the Registered Person moves toward a staffing ration recommended by the Department of Health Staffing Forum. It is recommended that all staff have a training profile added to their personal file. Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 20 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 Chataway Residential Home DS0000061583.V254858.R01.S.doc Version 5.0 Page 21 - 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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