Inspection on 31/10/07 for The Charlton Centre for Alzheimer`s and Dementia Care

This inspection was carried out on 31st October 2007.

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.

Other inspections for this house

The Charlton Centre for... 19/08/09

The Charlton Centre for... 25/02/09

The Charlton Centre for... 28/08/08

The Charlton Centre for... 26/02/08

The Charlton Centre for... 19/10/06

The Charlton Centre for... 29/11/05

The Charlton Centre for... 11/08/05

The Charlton Centre for... 20/12/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Charlton Centre for Alzheimer`s and Dementia Care Carlinghow Hill Batley West Yorkshire WF17 0AE Lead Inspector Helen Battle Key Unannounced Inspection 31st October 2007 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 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.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. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Charlton Centre for Alzheimer`s and Dementia Care Carlinghow Hill Batley West Yorkshire WF17 0AE Address 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) 01924 473333 01924 444344 ivor@charltoncare.com Charlton Care Homes Ltd Mr Ivor Charles Foster Care Home 67 Category(ies) of Dementia (67) registration, with number of places The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 67 19th October 2006 2. Date of last inspection Brief Description of the Service: The Charlton Centre for Alzheimer’s and Dementia Care is registered to provide a service for up to sixty-seven elderly people with dementia who require nursing care. The home is a large detached stone built property that was converted into a care home from the former Batley General Hospital. The home has three floors connected by a passenger lift. The home is situated on Carlinghow Hill close to Nightingale Cottage Nursing Home, its sister home. Local amenities are within ten minutes’ walking distance. The home is well served by public transport. There is ample parking space at the home. The provider informed the Commission for Social Care Inspection on 31st October 2007 that the fees range from £464.00 to £1,786.35 per week. There are additional charges for hairdressing, newspapers, and magazines. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, an unannounced visit to the home took place. Two inspectors visited the home from 09.30 hrs to 17.15 hrs. One inspector returned to the home the following day to check on immediate requirements given on the first day of the visit and to meet with the provider to give feedback about the findings of the visit. Whilst at the home, key documents that give information about how people are looked after and how the home makes sure staff are fit to work at the home were looked at, and so were the rooms and garden. Four members of staff were spoken with. Before the visit, the manager was requested to provide CSCI with information about the people who live at the Charlton Centre, the staff that work there and any incidents or accidents that have happened there since the last inspection. This was returned to the Commission prior to the visit taking place, also a selfassessment as to the quality of care the home is providing. This information has helped form the judgements made about how the home is performing. Surveys were sent out to the relatives of ten people living in the home, and to people’s doctors and social workers. At the time of writing this report, four relatives had responded. The responses were generally positive, with the exception of a comment about staff not appearing to be trained well enough. Relatives spoken to on the day of the visit indicated that they would feel able to raise any concerns, that staff are friendly and helpful and that overall the care is good. People commented favourably about the food. Feedback from staff was mixed, with some saying that they have supervision and feel supported and others saying that they do not. The staff spoken to were positive in their feedback about the manager Mr Foster and that he tries hard to support the staff team. What the service does well: People are properly assessed prior to admission. Positive interaction between some staff and people living in the home was observed during this visit. The newly opened unit provides a high standard of accommodation. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Each person’s care plan must reflect all their current identified needs. Medication must be stored, handled, administered and disposed of safely. Records of medication must be accurate and up to date. The building must be kept in good state of repair. Attention should be given to the windows, guttering and down pipes. The bathroom on Willow Unit must be made safe and suitable for people to use. Standards of cleanliness in the home must be improved. Wheelchairs must be kept clean and in good working order. Staff must be trained and competent in moving and handling people safely. Appropriate references, evidence that people are able to work in this country and full employment history must be obtained prior to staff commencing work at the home in order to protect the people living in there. Staff must be suitably trained in moving and handling, health and safety, fire safety and safeguarding to ensure the safety and wellbeing of people in their care. The registered person must ensure that a monthly visit is made to the home and a report regarding this visit is completed regarding the conduct of the home. All staff must have suitable training in fire prevention and be aware of the procedure to be followed in case of fire. Activities should be provided to suit the likes and preferences of individuals. The dining room on Willow unit should be refurbished and decorated to create a more pleasant environment for people to eat. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 7 All staff should have refresher training regarding Adult Protection (safeguarding) in order to ensure the protection of the people living in the home. People living in the home must be properly supervised. Staff should be deployed to meet the needs of the people living there. The manager should be supported to ensure he is able to discharge his responsibilities fully. Confirmation should be sent to the Commission in writing that the residents’ bank account is non- interest bearing. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 8 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 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: This home does not provide intermediate care. The records of four people were looked at and contained evidence of a pre admission assessments. These were in the form of a Community Care Assessment and/or a pre admission assessment carried out by the manager of the home. Responses in surveys from relatives indicated that family members are able to visit the home prior to admission in order to make an informed choice about whether the Charlton Centre for Alzheimer’s and Dementia Care is suitable to meet their relative’s needs. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The level of care people need, which includes their health, personal and social care needs are not clearly highlighted within their care plan. EVIDENCE: The care plans of four people living at the home were looked at. These included risk assessments regarding tissue viability (the risk of developing pressure sores), falls, mobility, nutritional status and continence. These risk assessments had not always been completed properly. One of the assessments had not been signed for three consecutive months by the person carrying out the assessment. One person had not had a risk assessment completed regarding their nutritional status for ten months. This person was also recorded as having lost weight. Risk assessments must be carried out properly and dated and signed to ensure that risks are correctly identified and managed. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 11 Care plans were in place and generally set out how people’s individual needs should be met. There were no care plans in place regarding activities or the emotional needs of people. For one person who had received support from the speech therapist regarding help with eating, there was no care plan relating to this. This lack of detail could potentially put this person at risk when eating. Care plan reviews were poor. They did not reflect how the care plan had actually met the needs of a person or not. The daily records examined were poor. The same phrases were used throughout such as: “hygiene needs met, safety met, dignity maintained”. These entries do not reflect what actual care and support has been delivered, how people’s needs have been met and where and how people have spent their day. This is not acceptable. Most of the people living at the home on the day of this visit, looked well kempt, comfortable and relaxed. A number of people did not have appropriate footwear on. People responded well to the staff and there was evidence of good practice from two members of staff. One person was seen to be sitting with a member of staff looking at a newspaper. The person was pointing out what they wanted to look at and talk about and the member of staff was facilitating this in a pleasant and relaxed manner. Another member of staff was seen to manage a difficult situation in a calm and professional manner. Issues have been raised regarding the lack of communication between staff and relatives since the last key inspection. This issue was discussed with the manager during the visit and this practice must improve to ensure better outcomes for people living in the home. The healthcare needs of people are met, evidence was seen of involvement from GPs, optician, dentist and other healthcare professionals where needed. The medication of two people was checked. There were discrepancies in the recording of medication, whether medication had actually been administered and issues regarding the safekeeping of medication. Loose tablets were found in bottom of the medicine trolley, tablets were pushed back into open blister packs, and different types of tablets were found together in the same blister pack. This is poor practice and puts people at risk. The medication fridge was dirty, it had sticky liquid spilled in it, hair was stuck to this and the fridge was thick with ice. An immediate requirement form was given regarding this at the time of the visit, and the fridge was found to have been cleaned at a further visit the following day. During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The lifestyle at the home appears to satisfy the needs of the people living there, and encourages the involvement of family and friends. EVIDENCE: During the visit individual people were seen to be participating in various activities including listening to the radio, looking at newspapers and receiving visitors. Visitors were seen to come and go to the home throughout the day. The hairdresser visits the home most days. A designated hairdressing room is provided at the home and looks like a hairdressing salon. This is a good facility for the people who want to use it. Activities recorded as taking place included summer fayre, bingo, one to one time, painting nails, baking, art, outside entertainers, table games and reminiscence. The dedicated activities co-ordinator works hard to try to improve the quality of life for people with the support of the care staff. A Halloween party was being held during the afternoon of this visit. Three people are supported to go to a local place of worship on a weekly basis. A quiet room is available for people to use should they want to practice any faith. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 13 In the care records of one person, their preferences of how they like to spend their time had been recorded on admission. This is good practice, however the activities then offered to this person had no reflection on these preferences and as a result this person was refusing the activities offered on a regular basis. People’s likes and preferences should be taken into account when offering activities. Due to the mental health problems suffered by the people who live at The Charlton Centre, it is very difficult to ascertain their views or how individuals make choices. Choices are, however, promoted as to what time people get up, go to bed and what they eat. During the feedback visit people were observed to be eating their lunchtime meal on one of the units. People appeared to be enjoying the meal and feedback from relatives surveys indicated that the food provided is of a satisfactory standard. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People can be confident that their complaint will be dealt with effectively and that they are adequately protected from abuse. EVIDENCE: All staff have received training regarding safeguarding (adult protection) in June or September/October 2006. Refresher training should be given annually to ensure that staff are up to date in how to recognise safeguarding issues and how to follow the correct policy and procedure in dealing with them. A specific issue regarding safeguarding was discussed with the manager during this visit, who agreed follow up action to address outstanding staff training. The complaints procedure is displayed at the home and in the policies and procedures file. Relatives spoken to during this visit indicated that they would know how to complain should the need arise. The complaints log was checked and documents were seen that complaints are dealt with appropriately. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is safe and is well maintained in some areas but not in others. The standard of decoration and furniture in the home is much improved, however some areas of the home were not clean and smelled of urine. EVIDENCE: The major building and refurbishment work on one unit in the home has been completed and the new unit was opened in September 2007. This accommodation in this unit has been completed to a very high standard. The rooms and hallways are spacious and light and much research has been carried out into selecting suitable furnishings and décor for people suffering from Alzheimer’s and dementia. The providers should be commended on this. The other two units in the home, however are in need of improvement and this has already commenced. A new shower room has been fitted on one of the units and decorating work was in progress during this visit. New furniture has The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 16 been purchased for many of the bedrooms and a new decking area has been developed outside for people to access safely. The manager stated that more work is to be done on this area to improve access further for the people living in the home. During this visit a light fitting in one of the toilets was not safe and a toilet seat was missing. These two issues were immediately rectified by one of the maintenance staff. One of the bathrooms was in a poor and unsafe state. The bath was dirty and the surface of the bath was cracked. There was a patch of floor covering missing, resulting in a tripping hazard and a potential infection control issue. Pipes near the bath were exposed. There were dirty razors in the bathroom cabinet. The sink was cracked. There was no light bulb in the strip light, the commode chair had rusty legs and the soiled pads in the clinical waste bin had not been bagged up resulting in a foul odour and an infection control risk. An immediate requirement form was issued to the manager during this visit stating that this bathroom must not be used until all these issues had been addressed. At the feedback visit the following day, the bathroom had been stripped, the bath removed and work was already underway to refit the bathroom, along with new flooring and tile the room throughout. Also on this unit the dining room was dirty and four wheelchairs were lined up outside the toilets, blocking the access. These wheelchairs were heavily soiled with food debris. An immediate requirement form was also issued regarding this matter. The following day during the feedback visit, the dining room had been cleaned to a satisfactory standard and the wheelchairs had also been cleaned. The general standard of cleanliness in the home needs to be improved. There were a number of unpleasant odours in the home. These were raised with the manager at the time of this visit. Work is planned to continue on a garden area in the grounds to make it safe and accessible for service users. This is a positive move which will improve the quality of life for many service users. The requirement made in the last two reports regarding the condition of the external window frames has been partly addressed with the majority of the front of the home having had the external window frames painted. However there are still some areas which need attention and so the requirement remains in this report. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit. Staff are employed in sufficient numbers and receive induction. Ongoing training has lapsed. The recruitment process does not ensure that people are sufficiently protected by the home’s recruitment policy. EVIDENCE: Rotas were examined and reflected that staffing levels are in place to meet the needs of the people. Discussion took place with the provider during the feedback visit regarding staffing levels and staff employment especially on nights and the need for people to be sufficiently supervised by accessible staff all the time was emphasised. Staffing levels must be reviewed regularly by the manager and increased where the assessed needs of people dictate this. Training for staff has not been kept up to. Records indicated that 29 staff have had manual handling training this year. No staff have had any fire training since 29.8.06. All staff had adult protection (safeguarding) training in 2006, however no –one has received any refresher training regarding safeguarding. Dementia care mapping training has been completed by three members of staff, and ten people have completed the “yesterday, tomorrow, today” – Alzheimer’s training. Records of induction training were also seen. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 18 The recruitment records for four members of staff were examined. For one person there was no evidence of them being able to work in this country, nor was there a full employment history. For another person there was no reference from the previous employer. This is poor practice and does not sufficiently protect people living in the home. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is run and managed by a manager who is fit to be in charge and is run in the best interests of the people who live there. The financial interests of people are safeguarded. The health and welfare of everyone is not promoted. EVIDENCE: The registered manager of the home is a nurse who has an excellent knowledge and understanding of this client group. The quality auditing system introduced at the last key inspection has not been maintained. Monthly management visits have not been carried out and standards at the home have been allowed to deteriorate. The Commission is The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 20 concerned that the serious shortfalls raised during this visit had not already been highlighted by the provider. It is the responsibility of the provider to ensure that monthly visits have been carried out and a report produced regarding the conduct of the care home. If these visits had been carried out as required, the shortfalls in the care provision at the home should have been avoided. The personal monies of three people were checked and found to tally with the records held. Records were also seen of a residents’ bank account. Confirmation that this is a non-interest bearing account should be sent in writing to the Commission. The safety issues raised regarding the bathroom on one of the units and the absence of staff training in fire safety are outlined in the environment and staffing sections of this report. Weekly checks of the fire alarm and emergency lighting system are recorded as being carried out weekly. Monthly checks of the hot water temperatures are recorded. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 21 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 1 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 22 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. 2. Standard OP7 OP9 Regulation 15 13 (2) Requirement Timescale for action 30/11/07 3. OP19 23 (2) b Each person’s care plan must reflect all their currently identified needs. Medication must be stored, 01/11/07 handled, administered and disposed of safely. Records of medication must be accurate and up to date. The building must be kept in 31/01/08 good state of repair. Attention should be given to the windows, guttering and down pipes. Timescale of 31/12/05 and 12/02/07 not met. The bathroom on Willow Unit must be made safe and suitable for people to use. Standards of cleanliness in the home must be improved. Wheelchairs must be kept clean and in good working order. Staff must be trained and competent in moving and handling people safely. Appropriate references, evidence that people are able to work in this country and full employment history must be obtained prior to DS0000059693.V353963.R01.S.doc 4. 5. 6. 7. 8. OP19 OP19 OP19 OP28 OP29 23 (2) b, c, d. 23 (2) d 23 (2) c 13 (5) 19 30/11/07 30/11/07 01/11/07 30/11/07 30/11/07 The Charlton Centre for Alzheimer`s and Dementia Care Version 5.2 Page 23 9. OP30 18 (c) 10. OP33 26 11. OP38 23 (4) d staff commencing work at the home in order to protect the people living in there. Staff must be suitably trained in moving and handling, health and safety, fire safety and safeguarding to ensure the safety and wellbeing of people in their care. The registered person must ensure that a monthly visit is made to the home and a report regarding this visit is completed regarding the conduct of the home. This report must be forwarded to the Commission until further notice. All staff must have suitable training in fire prevention and are aware of the procedure to be followed in case of fire. 31/12/07 30/11/07 30/11/07 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. Refer to Standard OP12 OP15 OP18 OP27 Good Practice Recommendations Activities should be provided to suit the likes and preferences of individuals. The dining room on Willow unit should be refurbished and decorated to create a more pleasant environment for people to eat. All staff should have refresher training regarding Adult Protection (safeguarding) in order to ensure the protection of the people living in the home. People living in the home must be properly supervised. Staff should be deployed to meet the needs of the people living there. The manager should be supported to ensure he is able to discharge his responsibilities fully. DS0000059693.V353963.R01.S.doc Version 5.2 Page 24 5. OP31 The Charlton Centre for Alzheimer`s and Dementia Care 6. OP35 Confirmation should be sent to the Commission in writing that the residents’ bank account is non- interest bearing. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V353963.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!