Care Home: 33 Charnhill Crescent

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What the care home does well The home has a structured admission process based on the homes ability to meet the assessed needs of individuals. Good standards of care and service delivery continue at the home. Those spoken with during the inspection said they were happy and enjoyed life at the home. The staff team at Charnhill are caring and have developed good relationships with those who live at the home; they have a sound understanding of the needs of residents. There is a low staff turnover and residents can therefore be confident that they will receive support from people they know. It was clearly evident that the manager and the staff team are committed to ensuring that all of the needs of individuals at the home are met, this is done through consultation, observation, previous knowledge and an understanding of individuals. A robust complaints procedure is in place and all complaints are investigated properly and action taken where required. The manager at Charnhill has a commitment and drive in wishing to provide a good quality service at the home, ensuring that individuals, their relatives and staff are consulted. There are clear lines of accountability within the home and within the organisation. What has improved since the last inspection? The home has met all four of the requirements made at the last inspection The Statement of Purpose has been revised and now includes information about the registered provider and registered manager ensuring that clear comprehensive information about the home is available to everyone. Residents benefit from expanded care plans that fully reflect the needs and support of individuals accommodating their choices and preferences. A `lone working` policy has been developed to ensure staff know who to contact and when to ensure a continuity of staff provision and safety for residents in an emergency. Residents now benefit from regularly reviewed risk assessments to ensure that best actions to minimise risk are in place and carried out. CARE HOMES FOR OLDER PEOPLE Charnhill Crescent, 33 Mangotsfield South Glos BS16 9JU Lead Inspector Patricia Hellier Key Unannounced Inspection 17th March 2008 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 Charnhill Crescent, 33 DS0000003358.V360193.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. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnhill Crescent, 33 Address Mangotsfield South Glos BS16 9JU 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) 0117 3774018 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Joanne Ruth Bewley Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate persons aged 19 years and over requiring personal care 2nd February 2007 Date of last inspection Brief Description of the Service: Charnhill Crescent is a care home registered with the Commission for Social Care inspection to provide accommodation and personal care to four adults with mental health problems. The home is a detached, corner house in a residential area and has well tended gardens on all sides of the property. The home is a short walk from all local amenities. It is close to a main bus route to Bristol and is also very close to the Avon ring road. The home was originally registered to provide a service for five adults; however some time ago this was reduced to provide a home for three people. A fourth single room is available should it be required. The home has a first floor bathroom and a ground floor shower room with a separate toilet. The kitchen is well equipped and offers space for supporting individuals to maintain their independence. There is a small office area on the ground floor. The home is in good decorative order and well furnished. Those living at the home have chosen the way in which their rooms are decorated. The fees range between £327and £401.57 a week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. This information was provided in March 2008. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place over 6 hours on one day. Manager, Ms Bewley, was present throughout. The Registered Before the inspection the information about the home was received from the file held in the office, surveys received from three people who use the service, four relatives and four members of staff. The last inspection report was reviewed together with the completed Annual Quality Assurance Assessment (AQAA) form, from the provider. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We (The Commission) also reviewed all correspondence and regulatory activity since the last Key inspection. The accumulated evidence for this report comes from the above and also fieldwork that included discussions with three residents, one relatives, two staff and one Social Worker. Practices were observed and documents relating to care, recruitment and health and safety were reviewed. Of the four resident surveys sent three were returned. The replies indicated that their care needs are met by responsive staff, and they are provided with what they need. Comments from residents were “There is someone here all the time.” “I get out to do the things I like”. No areas of concern were raised. Of the four relatives surveys sent all were returned and all felt that their relatives were well cared for by competent staff. Comments from relatives were “I am happy that my relative is well looked after”. “Staff seem well chosen and caring people”. “They always seem to notice if someone is feeling low and act accordingly”. All relatives felt they were kept up to date with information regarding their relatives’ health and well being. There were no comments of concern. All residents and relatives spoken with told us that the home was good and the staff very kind. Comments received were “it couldn’t get better”. “Its home”. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 7 It is recommended that to fulfil their legal obligations the use of tippex in records is stopped. Any erroneous entries should be scored through and initialled to show that records have not been tampered with for the protection of residents. It is recommended that the homely remedies policy is reviewed and signed by the GP’s, to ensure they are happy that administering these products would not be in conflict with other prescribed medications for the residents safety and protection. 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. Charnhill Crescent, 33 DS0000003358.V360193.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 Charnhill Crescent, 33 DS0000003358.V360193.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): 1, 2, 3, 4, 5, 6 N/A Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide is comprehensive to provide prospective residents with information on which to make an informed choice. Residents benefit from a thorough assessment process to ensure that the home is able to meet prospective residents’ needs. EVIDENCE: Charnhill Crescent is a care home registered with the Commission to provide personal care and accommodation for up to four persons aged 19 years and over with Mental Health problems. All accommodated at the home are female and there are currently no vacancies at the home. Charnhill Crescent is owned and operated by the Aspects and Milestones Trust. The home is one of a variety of care services operated by the Trust focussing on services for adults who require support to live in the community. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 10 Residents are provided with a comprehensive Statement of Purpose and Service User Guide and all the information required to ensure they, or their relatives, have access to the relevant information at all times. The Statement of Purpose includes information regarding equality and diversity issues and the homes philosophy of care that includes meeting cultural and diversity needs. All residents spoken with had access to a copy of these and they were displayed in the entrance area of the home. Feedback from residents and relatives during the inspection process was that they received plenty of information about the home. All residents were aware they had a contract of residency and were happy with the provision that they receive. The contracts reviewed as part of the case tracking exercise were signed and contained information about fees and the obligations of the provider and resident. The contract terms and conditions were clear and understandable. There was evidence to show that the home had discussed these contracts with residents and they had signed their contract, as had the manager of the home. The registered manager carries out a needs based pre-admission assessment on all prospective residents. Admissions to the home take place once the registered manager is confident the residents care needs can be met. We saw in records that individuals are introduced into the home at a level and pace appropriate to them, through visits, meals, an overnight stay and then a month’s assessment period. This month allows time for the individual and the home to determine if the home is suitable to meet the individual’s needs, wishes and aspirations. The views of those already living at the home were also taken into consideration. The most recent resident when spoken with told us “I am very happy here, I want to stay, and I have made friends”. Staff spoken with told us “all of those living at the home are treated as individuals, with different views and values”. They gave us examples of how specific needs are met. We saw that staff have undertaken appropriate training that will equip them with additional skills and knowledge to meet the needs of older people. Intermediate care is not provided. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Personal and environmental risks are well managed. Medication administration and practices are satisfactory. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include all key personal information. All three care plans were inspected and all reflected clearly current identified health and social care needs. Clear actions to met identified needs were recorded and regular evaluation noted. Systems for monitoring an individual’s wellbeing are in place and concerns about health are quickly addressed. In the AQAA we are told “all residents have a mental health safety net, including trigger factors and where necessary guidelines as agreed with the psychiatric services”. This information was seen in all care records inspected. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 12 All individuals said they like living at the home, and that they feel well cared for, that staff listen and treat them well. They all knew that they have a care plan in place, and who to speak with if they have any concerns. Person centred care was evidenced through observations of practice and discussion with staff. In the AQAA we are told that the home plans to implement the idea “All about me” which will increase person centred care and resident involvement. Staff when interviewed were clearly able to describe all the needs of the residents, and demonstrated a person centred approach to care. Health care professionals such as GP’s and other health care professionals visit the home as required to carry out health care checks and offer advice and support to residents and staff. Evidence was seen of regular visits to the chiropodist and optician, and residents being taken to other appointments as needed. Resident’s comments supported this. All care plans contained well-formulated risk assessments for Manual Handling and falls. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. One resident said, “there is always somebody here if I need them”. While another told us “there is a good atmosphere, I can come and go as I please”. Daily records were up to date and written in a respectful manner. Clear information was in place in order to demonstrate that specialist physical and mental health services are accessed for individuals once an assessed need has been identified. One of the residents said; ‘Since I have been supported by the home I have been well (in my mental health) and I thank the staff for that.’ Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. Medication is well managed with clear records in place and lockable facilities are provided for the safety of residents. There are individuals who are supported to self medicate. The resident said that they like to deal with their own medication to maintain their independence. The staff who administer medication have received appropriate accredited training and a list of specimen signatures were recorded in the medicine administration record. Hand written prescriptions had not been signed for accountability purposes. Good practice guidelines recommend two signatures for hand transcribed entries on MAR sheets. The Homely Remedies policy is clear, but is not dated for review purposes, and is not signed by the local GP’s to demonstrate their agreement with it. This is recommended to ensure the safety of residents from potentially unhelpful interactions of these remedies with prescribed medicines. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 13 Information is held securely. The home has a policy on confidentiality. Staff were observed ensuring confidentiality when discussing individuals in the communal areas. Comments from residents included “my privacy is respected” and “staff always knock before they come in”. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from very flexible routines and menus. A variety of activities is offered, and resident’s right to choice and control over their lives is well respected, and encouraged. Friendly staff always welcome relatives and visitors. EVIDENCE: During the day we observed how staff responded to residents. We saw that residents were spoken to at regular intervals and no one was ignored or excluded. Residents were offered choices and were enabled to make decisions about their day. The daily records seen confirmed that the home was supporting individuals in respect of their personal goals. This was further confirmed in discussion with staff and two of the individuals living at the home. Staff support residents to participate in the local community in accordance with their assessed needs, individual choices and preferences for their enjoyment and well being. Staff ensure that information is given to residents Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 15 about local activities and staff support individuals both in and out of the home to participate in activities of their choosing such as visiting places of local interest, drama group, luncheon club, holidays and shopping. On the day of inspection one of the residents told us about a short break they had at the end of the year, another resident told us about the voluntary work they are involved with and how much they enjoy this part of their life. All of those living at the home said they maintain regular contact with their family and that family members are made welcome at Charnhill. During the inspection it was observed to be a busy household with a number of visitors, friends and relatives, coming and going. All three residents gave us feedback via the surveys in which they told us they receive the care and support they need. Staff listen and act on what they say and that staff are available when required. All knew who to speak to if they were not happy. Two also wrote “I am happy and like living here” There is a well-furnished comfortable dining room for individuals to have their meals in. The Home operates a rotating menu. Prior to the inspection the menu choices were looked at to see if individuals are being offered a wellbalanced and varied diet. All the choices seen were well balanced, traditional and varied. Those spoken with said they enjoyed being involved with the preparation of meals and shopping. Individuals said they enjoyed the choices and meals offered at the home. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that they are listened to and their requests acted upon. Residents feel safe in the home and are protected by knowledgeable and competent staff. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. There have been no complaints since the last inspection. Residents stated that if they were not happy about anything they would speak to the manager. Residents said that the manager and staff are very approachable and they would always raise any niggles with them. Two residents, who said they had done this, were very satisfied with the outcome. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, it’s just like home – we are one family”. A system for keeping clear records of complaints received with actions taken and outcomes are available should any complaints be received. The home has robust polices and procedures in place to ensure the protection of vulnerable adults. Staff interviewed were conversant with the home’s Adult Protection policy and demonstrated good knowledge of the adult protection procedure that should be followed if abuse is suspected. The home also has a Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 17 Whislteblowing policy which all staff are aware of and understand their duty of care in relation to whistle blowing for the safety of the residents. All of the staff interviewed had an understanding of what constitutes abuse and said they had received training. This was verified during inspection of training records. Feedback from residents stated that they felt safe and secure living at the home. Communication between individuals living at the home and staff was open and inclusive during the visit. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with homely, safe and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Satisfactory Infection Control practices are followed. EVIDENCE: Charnhill is a small residential care home, and is furnished to a high standard. The Home is situated in Mangotsfield and is close to private houses and a short distance from the local shopping areas of Staple Hill and Kingswood. The house is nearby to bus stops. This helps ensure residents can be a part of the community. The home is nicely decorated and well maintained with a welcoming atmosphere, and made comfortable with homely communal spaces. The Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 19 décor, fixtures and fittings are in good order. The lounges are furnished with a variety of suitable and comfortable chairs to suit residents’ needs. The home has a well maintained garden and patio area for residents to enjoy. The residents said how much they liked the garden. In the AQAA we are told a number of refurbishments have been made to the home to ensure that it provides a home that all residents like and feel they have ownership of. Two residents told us how they had been included in choosing the colours for the redecoration and how much they had enjoyed it. In then AQAA we are toldf that the home is aware of the need to provide a smoking area for residents. In discussion with the manager she told us she is reviewing this with the organisation and also the possibility of making the garden area more private for residnts. All of those living at the home have a single room. Individuals have a key to their room for their privacy and security. Two of the residents showed the inspector their private bedrooms, these were found to be well furnished and had been personalised in order to reflect individuals tastes, interests and hobbies. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. The home has good facilities for ensuring that staff and residents can maintain good hand washing practices, for the safety and protection of all. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from sufficient numbers and skill mix of competent staff to meet their needs. Training is provided in a variety of topics to ensure knowledgeable and competent staff for the safety and benefit of residents... EVIDENCE: There is a well-established staff team at the home. At the time of the inspection there were sufficient numbers of staff on duty to meet the needs of those living at the home. Residents spoken to said “the staff are kind and caring and always there to help.” The manager was able to demonstrate that she and the small staff team have developed good relationships with those who live at the home and have a sound understanding of their needs, wishes and aspirations to enable them to live a fulfilling life. Two staff were spoken with during the inspection and both had good insight into the care needs of the residents. Both staff were committed to providing residents with a homely and full lifestyle based on choice which echoed the underpinning aims of the Trust. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 21 During the inspection it was not possible to view recruitment record as these are held at the organisations central office. The manager told us that she was sure the recruitment processes had not changed since the last inspection and therefore residents are protected through the recruitment process. In the AQAA we are told “all new staff have a full induction with adherence to the recruitment policy and processes which include Criminal Record Bureau (CRB) checks”. Mandatory training in Health and Safety, Fire and Moving and Handling is provided annually to ensure current best practice guidelines are followed. This was confirmed by certificates seen, discussion with the manager and information recorded on training records. Staff are encouraged to undertake their National Vocational Qualification (NVQ) training. This ensures staff are competent to meet resident’s needs. A staff member spoke with great enthusiasm of training they have undertaken. This had included recent training about self harm, assertiveness and diabetes. She was able to demonstrate her knowledge and how she is applying it in the home for the benefit of resident’s health and well being. In the AQAA we are told that the home is planning to provide training for staff in the mental capacity Act 2005 and is impact on residnts and their care in the home. We are also told that they are exploring a more flexible staffing level to enable residents to access more activities and outings in the community. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 22 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, 32, 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. Residents benefit from a home that is well run, and whose interests are at the heart of decision-making. Quality assurance processes in the home are formal demonstrating that the home consults with residents, families and visiting professionals. Resident’s monies in the home are well managed for their safety and protection. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise for the safety of residents. EVIDENCE: The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 23 Staff interviewed stated they felt “well supported by an approachable manager”. A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents and relatives. Regular residents and staff meetings are held at the home and provide an opportunity for open discussion, to raise concerns, ideas and suggestions and to plan for the future. Minutes of these were seen and showed a variety of topics discussed. There are sound quality audit measuring processes in the home including an internal monitoring system whereby the manager of another home checks systems of work, reviews records and spends time talking with residents and staff. Residents’ monies held by the home were inspected and found to be accurate and to have clear records. Supervision for staff is provided both formally, and informally at hand over times and other times, when the staff discuss resident’s care needs and how best to meet them. Records seen supported the practices spoken of by staff and the manager. Records seen showed evidence that care practices for residents and training needs were discussed. Feedback from staff, in surveys and with those interviewed, told us “we are well supported by ongoing supervision and training”. Policies and practice guidance are provided in the home. They have been reviewed and updated in the last three years, thus current good practice is contained within them to provide clear guidance on best practice provision for the benefit of residents. Since the last inspection a Lone working policy has been implemented for the safety and protection of residents and staff. Information received indicated regular safety and fire checks are carried out. Information regarding certificates of safety checks, servicing of equipment and other required safety inspections was supplied. Staff spoken to confirmed that regular fire instruction and drills had taken place. Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 24 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. 2. Refer to Standard OP7 Good Practice Recommendations The registered person to ensure that Tippex is not used when errors in record keeping are made. Best practice is to strike through and initial. The registered person to ensure that the Homely Remedies policy is regularly updated, at least annually, and agreed to by the local GP’s for the safety and protection of residents. OP9 Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Charnhill Crescent, 33 DS0000003358.V360193.R01.S.doc Version 5.2 Page 27 - 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. 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