This inspection was carried out on 23rd February 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Carisbrooke Care Home 22 Carisbrooke Drive Mapperley Park Nottingham NG3 5DS Lead Inspector
Dee Shelvey Unannounced Inspection 23rd February 2006 10:30 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 Carisbrooke Care Home DS0000026423.V282467.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. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Carisbrooke Care Home Address 22 Carisbrooke Drive Mapperley Park Nottingham NG3 5DS 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) 01159605724 01159106613 Mr Abdool Raouf Sohawon Mrs Bibi Sohawon Mr Abdool Raouf Sohawon Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (20) of places Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Maximum number to be accommodated is 20 Any service user admitted under the category of PD will be 60-64 years old on admission 25th November 2005 Date of last inspection Brief Description of the Service: Carisbrooke Care Home is an older converted house set in the residential area of Mapperley Park about two mile form the city centre. The care home provides care for older people with nursing needs and is registered for up to 20 service users. The care home has a pleasant outlook, with safe attractive wellmaintained gardens to the front of the property, where car parking facilities are available. There are 12 single rooms and 4 double rooms, none of which have en-suite facilities. There are two lounge areas, dining room, opening into a dining area and a conservatory, where smoking is permitted. Two bathrooms and one shower room are provided and toilets are in close proximity to all individual service users rooms and communal areas. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours and focused on the standards not assessed and requirements set at the last inspection. The methods used were reading documents, examining records, discussions with the manager and one service user. Two visitors were spoken with and a limited tour of the building took place. What the service does well: What has improved since the last inspection?
Where residents have alternative meals to those on the menu this is recorded to ensure that it is possible to determine whether a satisfactory diet has been provided for individual residents. When medication administration record sheets are hand written they are now signed and witnessed as being correct. Social activities and individual interests are covered in care planning and the home is making efforts to provide more stimulation. One resident only speaks Hungarian and an interpreter is provided when her son cannot visit. This ensures that she always has someone to speak to each day.
Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 6. Service users had a written statement of terms and conditions with the home. Standard 6 is not applicable to this home. EVIDENCE: A sample of signed contracts were examined and found to be satisfactory. The room to be occupied was only handwritten on the top of the contracts. In order to prevent any misunderstanding this needs to be included in the body of the document so that it is clear that it is part of the contract. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10. The service users were treated with respect and protected by the homes policies and procedures for dealing with medication. EVIDENCE: Two care plans were examined and they covered all aspects of daily life. There was evidence that relatives are involved in care planning and that reviews take place regularly. Nutritional screening takes place and residents weight is regularly monitored, evidence was seen that advise from the dietician is sought where concerns are identified. Clear instructions were given on how to meet service user need and to preserve dignity. There was evidence that treating people with respect and of giving personal care with discretion was covered during staff induction training. Staff were seen to treat people with respect during the inspection and the service user spoken with confirmed that this was normal practice. The home had a satisfactory set of policies and procedures for the management of medications and drugs were securely stored. Only persons trained to do so administer medication and the records were accurate and up to date.
Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 10 Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Service users are satisfied with their lifestyles and able to exercise choice and have control over their lives. They receive a wholesome balanced diet at times convenient to them. EVIDENCE: The service user spoken with said that she got up and went to bed when she decided. She could choose how to spend the day; there was also some evidence in records that activities took place within the home. There was some limited information recorded on care plans regarding residents’ interests and hobbies. The neighbourhood was described as not very community minded but in good weather trips out were arranged. Visitors were made welcome and those spoken with during the inspection were satisfied with the service. Meals could be taken either in the dining room or where the resident chooses and although there were set meal times these could be varied to suit the individual. The menus operated on a four week cycle and appeared to provide a nutritionally balanced diet. The resident spoken with said she had plenty of food and it always tasted nice. Alternatives to the menu could be requested and after the main meal a record of food provided was kept in
Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 12 sufficient detail to determine whether the diet is satisfactory. At teatimes however the menu was unimaginative consisting of soup and sandwiches. The manager stated that residents did request and receive alternatives but there was no record of the fact. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 13 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): 17 Service users’ legal rights were protected. EVIDENCE: The home puts residents in touch with an independent advocacy service run by Help the Aged to ensure that they receive unbiased advice and assistance with their private affairs. Part of the needs assessment covers cognitive ability and when ever possible residents are assisted to register to vote. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 14 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): 23,24 and 26. The home offers a good standard of accommodation that is clean and pleasant. EVIDENCE: 5 individual rooms were inspected and each had been personalised by the resident. The rooms were well lit, had sufficient ventilation and the radiators were covered to prevent burning accidents. Adjustable beds were available for those in need and in double rooms privacy curtains were provided. The individual rooms and communal areas were well furnished, well decorated and clean. During the limited tour of the building no potential safety hazards were seen. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 15 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): 28 Service users were in safe hands. EVIDENCE: The home ensures that there is always one qualified nurse on duty with sufficient care assistants to meet residents’ needs. Care assistants are given induction training and encouraged to complete NVQs. All staff receive in-house training on health and safety and fire safety in addition anyone who handles food must complete the food hygiene course. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 16 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 and 33. The manager of the home is registered as competent for the job and the home was run in the best interests of service users but could ensure that this remains so by improving and expanding its’ quality assurance system. EVIDENCE: The manager is a registered nurse with 20 years experience both in private practice and the National Health Service. In addition he is a registered mental nurse, which is of benefit to residents with dementia or other mental health problems. The City Hospital runs seminars for nurses wishing to keep their practice up to date and the manager makes full use of these. The home had a very basic quality assurance system that consisted of seeking the views of service users annually using questionnaires. The questionnaires contained the service users name and this could result in people holding back from giving negative comments. The system would benefit from an expansion
Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 17 to include families and visiting professionals. A true picture of service satisfaction could then be built up. The results of surveys should be analysed and used to inform the homes development plan. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 18 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 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 X 17 3 18 X X X X X 3 3 X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X X X X Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No 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 OP33 Regulation 24(1)(3) Requirement The registered person shall establish and maintain an effective quality assurance system based on seeking the views of service users and their representatives and visiting professionals. Timescale for action 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations The teatime menu should contain more variety and a record of food served should include this meal. Carisbrooke Care Home DS0000026423.V282467.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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