Inspection on 01/02/06 for Carisbrooke Manor

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Carisbrooke Manor 19/06/07

Carisbrooke Manor 04/10/05

Carisbrooke Manor 09/11/04

Carisbrooke Manor 26/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Carisbrooke Manor Burringham Road Ashby Decoy Scunthorpe North Lincolnshire DN17 2AA Lead Inspector Beverley Hill Unannounced Inspection 1st February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carisbrooke Manor DS0000002904.V281124.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 Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Carisbrooke Manor Address Burringham Road Ashby Decoy Scunthorpe North Lincolnshire DN17 2AA 01724 289555 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) Kapil Care Homes Ltd Kirsty Sutton Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: Carisbrooke Manor is a care home registered to support forty-three older people. It is located on the edge of Scunthorpe, just off the road from Ashby to Burringham. The building has been added to over the years and as a result the majority of the accommodation provided is on the ground floor. The home has thirty-one single bedrooms, twenty-one of which are en-suite and six shared rooms, two of which are en-suite. The majority of bedrooms are situated around a central grassed courtyard that has walking and seating areas. Many rooms offer views of the surrounding countryside. There are three assisted bathrooms, one unassisted and a shower room. Toilets are provided in most of the bathrooms and in addition there are five single toilets strategically placed throughout the home. The home has three large lounge areas. Two of these have dining areas at one end and one remains as a quiet sitting room. The original part of the house has five bedrooms on the second floor that are served by both stairs and a passenger lift. The ground floor in this part of the building is used mainly for office accommodation, laundry and kitchen facilities. There is a large superstore, pub/restaurant, chemist, optician, drycleaners, petrol station and a golf course within half a mile of the home. The home is on a bus route from Scunthorpe and there is adequate car parking provided for staff and visitors. The whole feel of the home is pleasant with clean and homely surroundings. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The Inspector spoke to the manager, four care staff that were on duty at the time of the inspection and the activity coordinator. Throughout the day the Inspector spoke to nine people who lived in Carisbrooke Manor and received three feedback cards one of them from a relative. The inspector looked at a range of paperwork in relation to staff recruitment, staff training and supervision, quality assurance, care plans, medication records, activity logs, financial records and the maintenance of equipment. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a tour of the building. What the service does well: What has improved since the last inspection? The home had three requirements from the last inspection and these had been addressed straight away. Staff ensured that full instructions were written on the medication administration record when they had to transcribe medication. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 6 Daily recording about the care provided had improved. This was important as it ensured that issues highlighted on one shift were followed through to the next and avoided care being missed. The home had contacted the GP for one service user to discuss possible alternative arrangements for their medication to fit in with their lifestyle choices. 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 Manor DS0000002904.V281124.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 Manor DS0000002904.V281124.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): 5 Service users were able to have trial periods to gain information about the suitability of the home prior to a final decision about residency. EVIDENCE: The home had the facility to provide respite services when vacancies allowed in order for people to gain an insight into the home. The manager stated that service users were able to visit the home to look around and stay for a meal or the day to meet other people and staff and to obtain a feel of the home. This was confirmed in discussion with a service user who had recently arrived. They stated that their relative had looked around the home and arranged with the manager for them to come for lunch. They stated they were settling in very well. The homes statement of purpose and service user guide indicated the homes facility for trial stays and the first six weeks of residency was considered as such until a formal review was held. The manager confirmed that the trial period could be extended as required. Carisbrooke Manor DS0000002904.V281124.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): 8, 9 and 10 Service users health and personal care needs were met within the home. Closer supervision of one person’s self-medication will maintain their continued independence and ensure their safety. EVIDENCE: Medication was assessed fully at the last inspection and requirements made had been met. However during a tour of the building and discussions with people it became apparent that one service user who self-medicates had access to homely remedies that had not been signed into the home and was a little unsure about one of their medicines. The manager is to discuss this with them and clear up any confusion and ensure that a supervision system is put in place that enables the service user to carry on self-medicating but also ensures their safety. Care plans examined reflected the needs to respect privacy and dignity and service users spoken to described care that promoted these values. Comments were, ‘oh yes they knock on doors and are polite, Kirsty (the manager) wouldn’t have it any other way’, ‘your room is your room but if you need help then you get it’, ‘the staff are very nice, the young ones seem to move more quicker than the older ones’, ‘they always knock on doors and give you privacy Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 10 when you use the toilet, you’ve only got to ask if you need something’, ‘I see my daughter in my bedroom in private’. Improved recording of the care provided evidenced that service users health care needs were met and this was confirmed in discussions with service users. Carisbrooke Manor DS0000002904.V281124.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 and 14 The home provided a good quality of life for service users by providing social stimulation and promoting choice and decision-making. EVIDENCE: The home employed an activity coordinator for two hours a day, five days a week. Individual activity logs were maintained and satisfaction sheets completed after each activity. The home provided a range of activities, for example, arts and crafts, quizzes, floor netball, cake decorating, exercises, dominoes, bingo, cards, hangman, reminiscence, word games and hand and nail care. Entertainers visited the home and clergy administered religious services. The inspector joined in a game of dominoes and it was a very social occasion. Service users enjoyed bantering with the staff and each other. The home participated in a monthly coffee morning with the company’s other two homes. This had started recently and about three service users from each home met up at each home in turn for coffee and a quiz. This gave them an opportunity to meet other people, catch up with acquaintances and generally get out and about. The home organised a monthly outing to local facilities such as garden centres and an annual trip to the coast for service users and families. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 12 Service users felt they had control over aspects of their lives and were able to make choices. One person stressed to the inspector that Carisbrooke Manor was their home and they enjoyed coming back to it when they go out or stay with their family. One person stated, ‘ Kirsty (the manager) likes the home to be very relaxed’. Service users confirmed that routines were flexible for rising and retiring, breakfast and other meals could be taken in the bedroom or the dining room, and there were choices about food and drinks throughout the day. One service user was very active in the quality circle meetings and confirmed suggestions made by service users were listened to and acted on. The home had two meetings a month at which service users could air their views and a suggestion box. Another service user commented that they were funny with food but the staff respected their choices. Some service users managed their own finances and medication and had installed their own telephones. Bedrooms were personalised to varying degrees and people confirmed they were able to bring in their own possessions. Carisbrooke Manor DS0000002904.V281124.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): 18 The home protected service users from abuse by staff training and practices and adherence to policies and procedures. EVIDENCE: The home had a protection of vulnerable adults policy and procedure, which was in line with the local authority policy and procedure regarding referral and investigation. Training for staff in the protection of vulnerable adults from abuse was part of the homes induction process and training plan. The manager had a particular interest in the protection of vulnerable adults from abuse and had recently made contact with the local authority’s Adult Protection Coordinator in order for them to visit the home and give advice on an updated training package developed by the manager. During discussions with the inspector, staff demonstrated their awareness of policies and procedures and what to do in the case of suspected abuse. The manager was aware of referral procedures to the adult protection team. Staff recruitment practices were robust and helped to safeguard service users. Carisbrooke Manor DS0000002904.V281124.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): 20 and 24 The home provided a clean and tidy environment with plenty of communal space and the opportunity for service users to personalise their bedrooms. EVIDENCE: The home had three communal sitting rooms, each with dining tables at one end. The rooms were nicely decorated and furnished. One person particularly liked watching the wildlife outside one of the windows and pointed out rabbits, wood pigeons and molehills. The home was based around a courtyard, accessible via patio doors from the corridors, which had seating and a water feature. Service users spoken to liked the opportunity of sitting outside in the warmer weather. Service users spoken to were happy with the home in general and their bedrooms. They confirmed they were able to bring in items of furniture and pictures and ornaments to personalise their room. Those checked during the inspection were clean, tidy and welcoming. The bedrooms had privacy locks Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 15 and lockable facilities. The home was very clean and the staff worked hard to maintain the standards. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 16 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): 29 The home protected service users by adherence to robust recruitment policies and procedures. EVIDENCE: Three recruitment records were examined of new staff employed since the last inspection and all had appropriate documentation in place. When povafirst checks were completed and the staff employed prior to the return of the criminal record bureau check, there was evidence of stringent supervision recorded on the staff members file. This ceased when a satisfactory CRB was obtained and was replaced with formal staff supervision. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 17 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): 33, 35 and 36 Service users views were listened to and their safety and wellbeing were promoted by the inclusive style of management within the home. Service users were cared for by staff members who were well supervised. EVIDENCE: The home had an excellent quality monitoring system that consisted of questionnaires to service users, relatives and professionals visitors to the home. Audits were completed monthly to check aspects of the service including, medication, care plans, accidents, complaints, activities, the environment, staffing levels, quality time spent with service users, staff supervision and training. Meetings were held with service users, staff, managers and a quality circle group of service users and staff. The manager and training manager completed a quarterly environment check to look at redecoration and refurbishment needs. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 18 The manager met with the proprietors monthly to discuss any issues and action plans were produced from the results of surveys and audits. These were completed and evaluated for their effectiveness. Results of surveys and audits were displayed on the notice board for service users and families and an annual service review made available, a copy of which was sent to the CSCI. The manager held securely two personal allowances for service users. Individual records were maintained and when examined these tallied with receipts and monies held. The remainder of service users finances were managed by the service users themselves or their families. Lockable facilities were available in bedrooms for securing personal belongings and finances. The homes comfort fund was managed appropriately and service users were consulted about expenditure. Documentation evidenced that the staff team received formal documented supervision every two months and when spoken to staff confirmed they had daily access to senior staff or the manager for support and guidance. Supervision sessions covered a range of topics including service user issues, training needs and the homes philosophy. The manager had one to one sessions with the proprietors and managers meetings as part of the support network. Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 19 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 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x 3 x x x 3 x 4 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 4 x 3 3 x x Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 12(1)(a)& 13(2) Requirement The registered person must ensure that the service user who self-medicates has more effective supervision arrangements in place. The registered person must ensure that any homely remedies service users have are signed into the home. Timescale for action 10/03/06 2. OP9 13(2) 10/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Carisbrooke Manor DS0000002904.V281124.R01.S.doc Version 5.1 Page 22 - 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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