Inspection on 02/05/06 for Abbotsbury

This inspection was carried out on 2nd May 2006.

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

Abbotsbury 01/11/07

Abbotsbury 17/05/07

Abbotsbury 22/02/07

Abbotsbury 09/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Carlton The 25 Park Road Southport Merseyside PR9 9JL Lead Inspector Mrs Elaine White Unannounced Inspection 09.15 2 and 4th May 2006 nd 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 Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 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. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Carlton The Address 25 Park Road Southport Merseyside PR9 9JL 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) 01704 537117 01704 537117 Ramos Healthcare Limited Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th November 2005 Date of last inspection Brief Description of the Service: The Carlton is a care home providing accommodation for up 21 older people who need personal care and support. Ramos Health Care has recently taken over the ownership of the home and is yet to appoint a registered manager. The Carlton is situated in a quiet residential area not too far from the centre of Southport and its amenities. It is within easy reach of the local park and public transport. The home is a large detached 3-storey building with 19 single rooms and 1 double that is currently being used as a single. There is a large well-kept garden to the rear and side of the property with garden furniture recently purchased for the residents. The home is well maintained internally and externally with good quality furniture and fittings. There is a passenger lift servicing all floors. The current rate of charges is £355 - £365 per week. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. It was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. The site visit also consisted of a complaint investigation. The home had received a visit in February 2006 to investigate a complaint on the services provided. During this site visit a further complaint was investigated and the findings and action to be taken by the provider are being addressed through the complaint procedure. A tour of the building was conducted. A selection of care staff and home records were also viewed. During the inspection 3 residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. The owner, six staff members, three of the seventeen residents, a district nurse and a collective group of residents were spoken with and their views obtained of the home. Survey forms were also given to residents to complete. Comments received from residents were favourable regarding the home and the very caring nature of the staff. What the service does well: Residents spoken to said they are satisfied with the care they receive and are pleased with the staff who are friendly and polite at all times. The health care needs of residents were being met and comments from residents include, “The staff are lovely”. Assessments take place for all prospective residents to ensure their needs can be met. The likes, dislikes, past history and interests of the residents are assessed on admission. An activity organiser attends twice a week and the programme includes quizzes, gentle exercise, games, trips out and crafts. Residents interviewed said they enjoyed the activities. One new resident who is staying for short-term care, commented, “I am very happy with the care. The staff are very helpful. I would recommend this home if I had to stay in permanently”. Medical referrals are made when needed to other health professionals and records are made of any visits made and action taken. Discussion with a visiting district nurse took place who commented, “The home is fine. The staff are good and follow care instructions”. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 6 Residents confirmed that they enjoy the food and there are always alternatives. Menus are displayed in the dining room. Residents were observed to enjoy their lunch in a pleasant, unhurried atmosphere. Staff are available to assist were needed in a discreet manner. The home was found to be comfortable, clean and homely. What has improved since the last inspection? What they could do better: Two staff files viewed showed that up to date Criminal Record Bureau Checks (CRB) were not in place. CRB’s are not transferable and a Protection of Vulnerable Adults POVA first check must be completed for all new employees. These must be obtained prior to employment for all employees to ensure the safety of the residents. The home must ensure that the correct recruitment and selection procedures are followed. This was discussed with the owner during the inspection and a requirement is contained within this report for action. An up to date training plan should be available to demonstrate staff training needs, training provided and required. This training plan should include – manual handling, fire safety, food hygiene, first aid and infection control. Hoist equipment is in place and must be provided with an up to date certificate every 6 months to ensure the safety of the residents. This is not being used at present for any residents. Portable appliance testing should be completed every 12 months on all electrical appliances in place. Staff administering medication should follow medication policies and procedures in place. This includes countersignatures for all written entries on Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 7 the MAR sheets and drugs received and recorded on the MAR. The administration of Controlled Drugs must be recorded (and witnessed) in a bound, paginated Controlled Drug register. Controlled Drugs should be stored in a Controlled Drug cabinet which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. Training in medication should be provided for care staff and the senior staff on duty to be responsible for administrations. The home must appoint an experienced and qulaified manager who has been approved by the Commission for Social Care Inspection, (CSCI). Staff meetings should take place regularly and formal supervision of care staff must take place at least six times a year. To provide support, direction and improve communication at the home during the transition of new ownership and manager. The findings of the complaint investigation which took place during this visit identified a number of requirements which are to be adressed by the provider within specific time scales set. An action plan demonstating how these are to be adressed is to be forwarded to the commision for social care inspection. (CSCI) and dealt with through the complaints procedure. The home was found to comfortable, clean and homely. A number of repairs were highlighted and include – window in bathroom requires catch, new windows in room 12, light bulbs to be in place on all hallways, decorate landing ceiling, decorate groundlfloor toilets, repair sink in hairdressing room and remove electrical equipment from the room, Radiator cvers are fitted in some areas, ensure risk assessments are in place were there are no covers. The basement food storage area is in need of organisation for the food to be stored correctly. The laundry facilities are well organised. The home’s has a maintenance book which records any repairs required. Ensure that records are kept of hot water temperature to baths, hot water sinks and shower rooms. . 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. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 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 Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. The quality in this outcome area is good. This judgement has been made using available evidence, including the complaint investigation and visit to this service. Residents are provided with the information they require to make an informed choice about living in the home. Full assessments of need are conducted prior to admission to ensure that the home can meet their needs. Respite care is provided on a short-term basis when vacancies allow. The home must only admit residents in line with their registration. EVIDENCE: The manager and/or senior care staff undertake an assessment for all potential residents. Assessments for three residents were viewed; this included an assessment of a resident recently admitted for respite care. It was found that the resident was under 65 and a variation had not been applied for by the home. This was required by the manager at the time of the site visit. Assessments contained sufficient detail with regard to personal/social information, general past medical history, medication and current health care needs. Specialist intermediate care is not provided at the home. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 10 Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The quality in this outcome area is adequate. This judgement has been made using available evidence, the complaint investigation and visit to this service. Resident care plans reflect current health care needs and the actions that are required by the staff to meet those needs. The home has a policy and procedure for medication administration however further training is required. EVIDENCE: The care files of three residents were viewed. Residents have an individual care file and the plan of care is based on the initial assessment. The care plans evidence the daily activities of living with reference to diet, mobility, personal hygiene, continence and social background. Care plans are generally reviewed monthly to reflect any change in the condition of the resident and any change in treatment or medication, however some care files had their last review in Feb 2006. Discussion took place with one resident and the owner regarding his change in care needs. A review was recommended to involve all those involved in his care and a new care plan to be implemented. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 12 General risk assessments including manual handling instruction are in place for those are at risk of falling or who require assistance with their mobility. Not all residents sign to say their have read and understood their plan of care. A resident stated, “The staff are all very caring and kind. I just ring the call bell if I need help and they come. ” Residents spoken with said that they were able to visit GP’s opticians and dentists as needed. Care files viewed evidenced visits by GPs and the district nurse visits. District nurses maintain their own notes and advise staff of the treatments they are giving. One visiting district nurse was spoken to and commented. The home is fine and staff follow instructions given. The home must review the medicine policy and procedures with all staff in view of a number of areas identified during the inspection. These are included within the recommendations and requirements of the inspection report and were discussed with the owner during the inspection process. These include - All staff responsible for administrating medication should be trained in medication, written records on MAR should be countersigned, controlled drugs book to be obtained with numbered pages and records maintained of all administrations and balance, with no gaps in record. Two staff sign controlled drug administrations. The CD must be stored in a locked box in a locked cabinet. They are presently stored in the meds trolley. Residents are requested to sign an agreement for self medication and this was confirmed on care files and discussion with one resident who self medicates. The MAR sheets evidenced staff signatures following administration of medication. The medicine trolley is kept securely locked to an inside wall in the dining room. Residents gave examples of how staff treat them with dignity and respect, “staff are very polite and help me with my personal care”, “The staff are lovely”. Staff were observed during the day to speak to residents in an appropriate manner and also spending time chatting in the lounge and dining room. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality in this outcome area is good. This judgement has been made using available evidence, including the complaint investigation and visit to this service. The home is able to demonstrate that residents are encouraged to be independent and have a choice regarding how they wish to spend their day. Their rights are respected. EVIDENCE: The home presented a pleasant atmosphere and visitors were made welcome. Residents confirmed that they enjoy the social activities that are arranged ‘in house’. The home offers bingo, chess, puzzles, scrabble and musical entertainment, which was taking place during the visit . An activity organiser attends twice a week to do quizzes. Residents were observed to enjoy the entertainment. The hairdresser attends weekly. The routine in the home was observed as being based around the needs and wishes of the residents and a resident said, “I choose when I get up and go to bed”. Another resident said, “I like to have lunch in my room and breakfast and tea in the dining room”. Staff were seen to be supportive to the needs of the residents and were cheerful and warm in their approach. Residents confirmed that their visitors are made welcome at any time. One residents friend call weekly to take him Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 14 out and he also has communion weekly. Some of the residents are independent and require little personal support, however discussion with them confirmed that staff are always on hand to help with walking, bathing and dressing. One resident said, I need help to put my shoes on. I just ring the bell and they come. Residents are encouraged to manage their own finances and staff also assist with financial arrangements when required. Financial files for three residents were viewed, these evidenced details of recent financial transactions. The home is currently responsible one residents financial affairs. One resident requested that his personal allowances are paid on the same day each week. this was discussed with the owner who discussed this with the resident immediately. Residents are surveyed annually to obtain their views on the home. Lunch was served in the dining room by the care staff. The dining room tables were attractively laid. The home offers three meals a day with snacks at various other times. The menu for each day is written on the menu board in the dining room and a weekly menu displayed. A hot meal was served and discussion with the residents at lunch confirmed that there is an alternative available. Staff also confirmed that there was and they had a good knowledge of what residents enjoy from their care records and by daily discussion to obtain their choice for the day. Care files viewed had a record of food preferences and this information had been passed to the cook. The cook spoken to is employed on a temporary basis due the sickness absence of permanent cook. Birthdays and special occasions are celebrated. Fridge and freezer temperatures had been recorded daily and the kitchen appeared clean and well equipped. The home had a good supply of fresh, frozen and dry foods and the cook is able to purchase what she needs. Residents were generally complimentary regarding the food. “There are always alternatives”. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 15 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. The quality in this outcome area is adequate. This judgement has been made using available evidence, including the complaint investigation and visit to this service. Residents are aware of how to make a complaint, however the complaints procedure is not displayed for visitors to access. The home has a policy and procedure to protect residents from abuse, which must be used to investigate complaints against the home thoroughly. EVIDENCE: The complaint’s procedure is not displayed. The complaints procedure is contained in the service user guide and residents spoken to confirmed they had a copy and are aware of how to complain. The owner confirmed that this was available on request, however no copy was displayed. The home has a complaint log and one complaint has been raised ‘in house’ and two further investigations required by CSCI. The requirements of the complaint made in February 2006 have all been adressed. These include choice of meals, more activities and wieght records. The complaint investigation as part of the inspection found all areas of the complaint to be upheld and regulations not met. The home has been required to take action within agreed time scales under the complaints procedure. Discussions with staff detailed that they would always speak with the manager if a resident raised a concern. A resident said, “I know how to make a complaint. But I have never had to make one”. The home has the latest Sefton guide for protection of vulnerable adults however staff are not familiar with this latest document or have received any Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 16 formal training. The owner confirmed that this is to be circulated to staff. Discussion with staff confirmed their awareness of the whistle blowing policy and a staff member said, “I would always report anything if I was concerned”. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 17 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. The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in pleasant, safe, comfortable and well-maintained surroundings. EVIDENCE: A partial tour of the building evidenced a good standard of décor, fittings and furnishings. All areas seen were clean and tidy. Residents interviewed said that their rooms are clean and tidy. Several bedrooms were viewed and these were furnished to individual taste and residents had brought in personal items e.g. electrical equipment and ornaments. Bathrooms were equipped with aids to help residents who are less independent . The lounges had comfortable armchairs and the dining room seated small groups of people. The gardens are well maintained. There is a ramp to the main front door and residents have the use of a passenger lift. A number of repairs and decoration required was Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 18 noted and brought to the attention of the owner. These inlude - repair and decorate ground floor toilets, repair window catch in upstairs bathroom,replace windows in room 12 due to gaps in windows, decorate landing ceiling, hairdressing room - repair sink and remove electrical equipment, ensure light bulbs are in place on all light fittings. Radiator covers are fitted in some areas,however the home to ensure risk assessments are in place were there are no covers. The basement food storage area is in need of organisation for the food to be stored correctly. The laundry facilities are well organised. The home’s has a maintenance book which records any repairs required. Ensure that records are kept of hot water temperature to baths, hot water sinks and shower rooms. Legionella is checked regularly 1/6/06. Hoist equipment is not used at present, however this must have an up to date certificate to ensure safe use. Residents were complimentary regarding the upkeep of the home and the standard of equipment provided. Emergency lighting is provided throughout the building and subject to a full maintenance contract. Residents have the use of a call system with alarm facility in their bedrooms and staff were observed answering calls for assistance quickly.Discussion with the owner took place regarding long term maitenance plans. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The quality in this outcome area is poor. This judgement has been made using available evidence, complaint investigation and a visit to this service. Residents are not protected by the home’s recruitment policy and staff require training in safe working practice areas to ensure they can deliver the care required. EVIDENCE: The home has recently been taken over by new owners. The home is currently well staffed and the staff rota evidenced a satisfactory number of staff on duty to care for the residents. At the time of the inspection seventeen residents were accommodated. The home employs a manager, senior care staff and care staff. Domestic cover is provided during the week and care staff are responsible for the care of the laundry. The home has two cooks and the permanent cook is presently absent. The manager is also absent at present and the owner and senior care staff are responsible for the day to day running of the home. There are two care staff on duty at night. Where there is a shortfall in staffing numbers agency staff are used. A resident said, “The staff are lovely”.The files of two employees were examined and one evidenced completed job application form, two references, induction training and qualification certificates. No up to date CRB was in place. No up to date recruitment and selection procedures had been completed for the second file veiwed. This was discussed with the owner who was informed that CRBs are Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 20 not tranferable and all new employees must be employed using the correct procedures. Staff receive Staff Handbook. The induction material is based around the organisational structure of the home, its home’s policies and procedures and employment arrangements. A number of staff require training in safe working practice areas including, manual handling,first aid, basic food hygiene, fire safety infection control. Training records are in place and further training is planned for all staff to bring them up to date. This should include all statutory training. The majority of care staff have obtained NVQ Level 2 or are enrolled on the course.. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The quality in this outcome area is adequate. This judgement has been made using available evidence, complaint investigation and a visit to this service. The home employs a manager who has been approved by CSCI. There are however health and safety concerns with regards to lack of a maintenance certificate and also information recorded in policy documents to protect the residents. EVIDENCE: The home has recently bee taken ower by new owners. The home employs a full time manager who has not yet been approved by the CSCI and is presently absent. The manager is taking a National Vocational Qualification (NVQ) Level 4 qualification.The manager is supported by the owner who visits the home Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 22 weekly. Regulation 26 of the Care Homes Regulations monthly report is required to be submitted to the local Commission’s office to monitor the home’s progress. Discussions with residents detailed that the manager makes herself available at any time. One resident said, “Elaine (manager) is always around and we miss her as she is off sick ”. The new owners are not very hands on and are not always around. Annual satisfaction questionnaires are completed regarding the care and facilities at the home. Minutes of the most recent staff were available held March 1st 2006. Financial policies and procedures are in place and reciepts obtained for all transactions. The home is appointee for one resident. The manager is in the process of updating all the home’s policies and procedures in view of the findings of the recent complaint the manager is to introduce a system where by a policy document is distributed for staff to read and then they asked to sign to say they have read and understood the information. A number of certificates in safe working practice areas and equipment were examined. These were current for fire safety, lift, gas, electrics. Portable appliance testing and manual handling equipment failed to have up to date certificates. Staff supervision has yet to commence, either on a one to one basis or as group supervision. The owner cofirmed that informal supervision has taken place to “get to know the staff”. Discussion with a number of staff took place to obtain views on the new ownership and management of the home. The comments provided were not very complimentary regarding the ‘low staff moral’, ‘management systems’ and ‘lack of communication’ with staff. Staff commented that the care of the residents is their priority and this is being maintained. Discussion with residents confirmed their satisfaction with the care and support provided and the pleasant attitude of the staff. Staff training is to be brought up to date and the owner is to produce a training plan for all statutory training and others identified as a result of the complaint investigation. All accidents and injuries are recorded. Legionnella is regularly tested. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 23 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation Care Standards Act 2000 Part 11. 24. 18 23 Requirement Timescale for action 30/06/06 2. 3. OP9 OP19 The responsible person shall not admit residents under 65 years without a variation application agreed by the Commission for Social Care inspection. The home must make an application for one resident on short stay. All staff responsible for 30/06/06 administrating medication must be trained. The responsible person must 30/06/06 provide an up to date certificate for the hoist equipment in place. (Time scale not met 31/12/06). The responsible person must ensure that an experienced and qualified manager approved by CSCI is appointed. (Time scale not met 30/03/06). The responsible person must ensure the following improvements are made. These inlude - repair and decorate ground floor toilets, repair window catch in upstairs bathroom,replace windows in DS0000065441.V292113.R01.S.doc 4. OP31 7 30/06/06 5. OP19 23 30/09/06 Carlton The Version 5.1 Page 25 6. OP18 22 7. OP29 19 room 12 due to gaps in windows, decorate landing ceiling, hairdressing room - repair sink and remove electrical equipment, ensure light bulbs are in place on all light fittings. Radiator covers are fitted in some areas,however the home to ensure risk assessments are in place were there are no covers. The responsible person must 30/06/06 ensure that the complaints procedure is displayed and available to visitors. The responsible person must 30/06/06 ensure that all staff are employed using the correct recruitment and selection procedures, which includes satisfactory POVA First check and two written references. 8 9 OP33 OP36 26 18 10 OP30 18 The responsible person must conduct regulation 26 visits. The responsible person must ensure that formal staff supervision takes place for all care staff. The responsible person must ensure staff are trained in safe working practice areas including, manual handling,first aid, basic food hygiene, fire safety infection control. 30/06/06 30/06/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Carlton The Refer to Good Practice Recommendations DS0000065441.V292113.R01.S.doc Version 5.1 Page 26 1 2 Standard OP18 OP9 The home has the latest Sefton guide for protection of vulnerable adults however staff are not familiar with this latest document and need training. The home should review the medicine policy and procedures with all staff in view of a number of areas identified during the inspection. These include - All written records on MAR should be countersigned, controlled drugs (CD) book to be obtained with numbered pages and records maintained of all administrations and balance, with no gaps in record. Two staff sign controlled drug administrations. The CD’s must be stored in a locked box in a locked cabinet. Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Carlton The DS0000065441.V292113.R01.S.doc Version 5.1 Page 28 - 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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