Inspection on 19/06/07 for Carisbrooke Manor

This inspection was carried out on 19th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 01/02/06

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 Mrs Kate Emmerson Key Unannounced Inspection 19th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carisbrooke Manor DS0000002904.V343984.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. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carisbrooke Manor Address Burringham Road Ashby Decoy Scunthorpe North Lincolnshire DN17 2AA 01724 289555 01724 277714 carisbrookemanor@tiscali.co.uk 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 Dementia (2), Dementia - over 65 years of age registration, with number (25), Old age, not falling within any other of places category (43) Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users who occupy the two DE beds must be over 60 years of age. 1st February 2006 Date of last inspection 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. The range of fees for the service were £327- £399 per week. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 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 staff that were on duty at the time of the inspection. Throughout the day the Inspector spoke informally to the majority of the service users in the home in their bedrooms or in the communal areas. The inspector also spoke at length to a District Nurse who visits the home daily as part of pilot scheme to prevent admissions to hospital. Surveys were received from 15 service users, 3 visitors/relatives and 9 staff, all of which were very complimentary about the service. A range of paperwork was examined in relation to staff recruitment, staff training and supervision, quality assurance, care plans, medication records, activity logs, financial records and the maintenance of equipment. A partial tour of the building and gardens was also completed. What the service does well: The service users were happy with the services received and commented that the care they received was ‘very good’ and that the staff were ‘very kind and supportive’. Much of the home had been redecorated in recent times and the home was very clean and tidy. All of the service users had an assessment of their needs made before they were admitted in to the home to make sure that the home would be suitable for them and their needs could be met. The service users stated that they enjoyed the meals provided and those seen were well presented. Staff were skilled at assisting those service users who required assistance. The management of the home was very open and anyone could speak to them at any time. The home had systems in place to ensure service users were protected from abusive situations. Adequate staffing levels were maintained and staff received regular training to make sure that they had the knowledge and skills to meet the needs of the service users. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 6 The service users had the opportunity to access a wide variety of activities both in the home and in the community. The registered manager was very organised and managed the home well. Staff training and supervision was a high priority. The proprietors were involved with overseeing the home and supporting the staff team. They visited the home regularly and were involved in quality monitoring. The home had a good system of monitoring the quality of the services it provided for people who lived there. The quality assurance system made sure that people had a say about the running of the home and those spoken to felt their suggestions would be listened to and actioned. The home had achieved a Gold Standard in the local authority’s Quality Development Scheme. What has improved since the last inspection? 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 Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carisbrooke Manor DS0000002904.V343984.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 Carisbrooke Manor DS0000002904.V343984.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, and 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users received information to assist them to decide if this was the right home for them. Their needs were assessed prior to them moving into the home and had been assured that the home could meet their needs. EVIDENCE: The home provided well-developed information about the service and the quality of life the service users could expect at the home. The service users were also provided with a letter with a summary of documents and where information relating to the home could be found. The manager stated that the documents could be produced in large print where required. A copy of the service users guide was available in the staff room and staff were aware of this Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 10 document. It is recommended that to make it fully accessible to service users the document should be on display in communal areas or in each bedroom. Four service users were case tracked and all their files contained detailed assessments of need that had been completed prior to service users being admitted to the home. The manager stated that either she or a senior member of staff would assess all service users prior to admission to the home. There was evidence that initial care plans were developed from the assessment prior to the service users being admitted and these were then developed in to full and detailed plans of care following admission to the home. There was evidence that service users had been issued with a contract/statement of terms and conditions on admission to the home and these contained information such as scale of charges and trial periods. One of the contracts did not detail the room to be occupied. The majority of service users indicated that they had received a contract and all stated that they had received information about the service to enable them to decide if this was the right place for them before they moved in. Carisbrooke Manor DS0000002904.V343984.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 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs were set out in detailed care plans and their health needs were met. Service users felt they were treated with respect and their privacy upheld. Medication was well managed in the home and service users were able to self medicate if they wished. EVIDENCE: Care plans detailed assessed needs and tasks for staff to meet those needs. They were evaluated on a monthly basis and there was evidence of reviews held with the service user, family and care management. The service user or their representative signed the care plans once they had agreed them. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 12 Detailed risk assessments were in place for all activities deemed to pose a risk. Daily records detailed the care provided and information as to the service users health. There was evidence that service users health was monitored and any concerns were referred appropriately to a health professional. Discussion with the visiting District nurse indicated that the home provides high quality care to the service users. She stated that there was a low incidence of pressure sores in the home and she had observed good moving and handling techniques used by the staff. She described how staff encouraged service users independence and used appropriate equipment to support this. Service users commented that they received ‘very good care’ and ‘very kind supportive staff’. Just one negative comment was received which stated that carers need to ‘check on us more often’ in regard to needing to use the toilet. The management of medication within the home was designated to one staff member who confirmed that they were given extra time, off-rota, to complete ordering and signing in of medication tasks. Generally medication was managed well, was stored appropriately and was signed-in on receipt into the home and on administration or disposal. Service users had regular medication reviews and information was available about any allergies. There was a system to capture any signatures that staff may have inadvertently forgotten on the MAR sheet. There were processes in place to risk assess and support service users who wished to self medicate. Staff had received training in this area. There was no evidence that the temperature of the medication storage room and medication fridge was regularly checked to ensure that the temperatures were within acceptable limits for storing medication and this is recommended. The staff member assisting the inspector was aware that this is good practise and a form to record temperatures had been provided. It was noted that one service user had not had their controlled medication as prescribed on one occasion as there had been no stock. There was evidence that this had been ordered in good time but had not been dispensed by the pharmacy. The manager stated that this had been followed up and was dispensed later that day. One service user commented that ‘ I am given my tablets on time and my legs are creamed twice a day, I am always asked how I feel’. Care plans examined reflected the needs to respect privacy and dignity and service users spoken to described care that promoted these values. They stated that staff knocked before entering their room and protected their privacy when giving personal care. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 13 Carisbrooke Manor DS0000002904.V343984.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 and 15 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users experienced a lifestyle that matches their individual needs and expectations. Family and visitors were welcomed into the home. The service users received a well-balanced and varied diet, which meets individual needs and choices. EVIDENCE: The home had employed an activity coordinator for two hours a day, five days a week, however she had recently left and a carer was covering this role until the new activities coordinator employment checks had been completed. 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. The service had also enjoyed a race night with snacks and wine provided by the home. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 15 Entertainers visited the home and clergy administered religious services. 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. Fund raising activities for the residents fund were also held in the home. Service users felt they had control over aspects of their lives and were able to make choices. 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 stated ‘that they couldn’t find fault with the home’. The home had regular monthly meetings at which service users could air their views and a suggestion box. Service users stated suggestions made by service users were listened to and acted on and the meeting minutes indicated that service users were confident to bring any issues to the table. 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. Service users spoken to confirmed that their visitors were made to feel welcome and could visit at any time. The home produced a newsletter to keep service users, relatives and the local communities up to date with events. The home produced four weekly rotating menus and these provided varied meals. There were choices at each of the meals throughout the day and staff and service users stated that alternatives would be provided if people preferred something else. There were positive comments about the choice, quality and presentation of the meals. Fresh fruit and vegetables were used each day. The kitchen was very well organised and very clean and tidy. The cook was knowledgeable about service users diets and was able to describe how individual needs were met. The kitchen records were very clearly maintained and very well organised. The menus were displayed in all the lounges. There were also bowls of fresh fruit available for people to help themselves. The dining areas were designated parts of two of the lounges and had separate tables to seat four to six people. The tables were well presented with condiments and napkins. Staff were skilled at assisting the service users and good practise was observed of a staff member assisting a service user who was vision impaired. Carisbrooke Manor DS0000002904.V343984.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 and 18 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provided an atmosphere whereby people felt able to make complaints. The home protected service users from abuse by staff training and practices and adherence to policies and procedures. EVIDENCE: The homes complaint procedure was clear and displayed in the entrance. The procedures were provided to service users on admission to the home. It had appropriate timescales for resolution and included contact details of other agencies. The home had a complaint form, which included aspects of the complaint, what action was taken, manager’s comment and evaluation. The manager completed a complaint summary form to keep track of complaints in order to plan changes to practice. Service users spoken to felt able to make any complaints they may have either to the manager, staff members or their families. Complaints received since the last inspection had been resolved. It is recommended that where the manager takes statements from staff as part of her investigations these should be documented and signed. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 17 The home had a safeguarding 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 safeguarding adults from abuse and had regular contact with the local authority’s Adult Protection Coordinator in order for them to continue to develop this area. 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.V343984.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 and 26 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provided a comfortable and safe environment for services users and staff. EVIDENCE: The home was well maintained internally and externally and was exceptionally clean and tidy throughout. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 19 Communal rooms and individual bedrooms were pleasantly decorated and furnished. There were three communal lounges for people to meet, two of which had areas for dining. The home had thirty-one single bedrooms, twenty-one of which were en-suite and six shared rooms, two of which were en-suite. The central courtyard was safe and water feature and garden furniture was provided. A training/meeting room had been built in the grounds of the home. The home was suitable for its intended purpose. The home employed maintenance personnel to deal with issues on a day-today basis. Staff spoken with reported that sufficient equipment was provided within the home and repairs or replacements made as required. Records of tasks completed were maintained. Quality assurance monitoring records and audits were maintained and provided evidence that the manager took a planned and well-organised approach to maintaining the home and the equipment provided. 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 and lockable facilities. The home was very clean and the staff worked hard to maintain the standards. One service user was to have their bedroom decorated and confirmed they had input into this and had decided on the timing for this event. Carisbrooke Manor DS0000002904.V343984.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 and 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provided a stable and safe environment for service users by the provision of trained staff in sufficient numbers. The home protected service users by adherence to recruitment policies and procedures. EVIDENCE: Staff rotas were examined and showed that there was seven care staff on duty during the morning and five in the afternoon. Three waking staff were on duty at night. The manager monitored the dependency levels of service users in order to influence the provision of staff. There were sufficient domestic and catering staff and the home employed staff to organise activities. The manager was supernumerary to the rota. Service users spoken to were very complimentary about the staff and there was a longstanding core group who had been working within the home for several years. Staff commented that staffing levels were ‘pretty good’. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 21 The proprietor’s commitment to training was evidenced by the employment of a training and development manager for the company’s three homes. Each staff member participated in three paid training days per year. These were planned well in advance and ensured that staff members were kept up to date. The staff training programme was well developed and included an induction course over five weeks, service specific training such as tissue viability, risk assessment, handling complaints, quality assurance, understanding osteoarthritis and catheter care, and ongoing mandatory training updates in fire, moving and handling and basic food hygiene. The home encouraged staff to take NVQ qualifications and information provided by the manager showed that 13 staff had achieved NVQ level 2 and 3 had achieved NVQ level 3 and 2 had achieved NVQ level 4 including the manager. One member of staff was registered to take NVQ 3 and 2 others to take NVQ level 4. Three recruitment records were examined of new staff employed since the last inspection. When POVA (Protection of Vulnerable Adults) first 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. There was some evidence that staff had been employed prior to two written references having been obtained but telephone reverences were recorded. The manager was advised that staff are not employed prior to two written references being obtained. Carisbrooke Manor DS0000002904.V343984.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, 33, 35 and 38 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users views were listened to and their safety and wellbeing were promoted by the inclusive style of management within the home. Staff members were well supervised. The manager was very well organised and highly regarded by staff and service users. EVIDENCE: There was evidence that the manager had completed the Registered Managers award and NVQ level 4 in care since the last inspection. She had worked for the company for fourteen years, initially as a senior carer then an assistant manager for eleven years until taking her current post in 2005. She had completed risk assessment training appropriate to her role. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 23 Via discussions the manager demonstrated a proactive approach to training, service user consultation and inclusion and promotion of quality within the home. She demonstrated throughout the inspection her excellent organisational skills, her high standards were evident throughout the home and staff and service users were complimentary about her management style. Staff and service user meetings were held monthly and minutes demonstrated that suggestions could be made and acted upon. Relatives were invited to the service user meetings and quality circle meetings were held monthly to discuss particular topics. A newsletter kept people informed of events within the home. 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. The home had achieved a Gold Standard in the local authority’s Quality Development Scheme. 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. Where the manager was holding money on behalf of service users individual records were maintained and when examined these tallied with receipts and monies held. Lockable facilities were available in bedrooms for securing personal belongings and finances. 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 arranged her working week and staff rotas so that night staff were also supported and supervised. The manager had one to one sessions with the proprietors and managers meetings as part of the support network. The manager was extremely well organised in the management of health and safety, ensuring that equipment was repaired and serviced regularly, staff members were appropriately trained, fire equipment was tested and staff Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 24 accessed regular fire drills. Individual risk assessments were in place for activities that posed a risk to service users. Accident reports were maintained and audited. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 25 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 4 X X N/A 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 2 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 Requirement The registered person should obtain two written references prior to employment of staff. Timescale for action 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP2 Good Practice Recommendations The registered person should ensure that the service users guide is accessible to service users by placing a copy in communal areas or bedrooms. The registered person should ensure that the contract details the room to be occupied by the service user to ensure that they have full information as to their terms and conditions. The registered person should ensure that the temperature of the medication store cupboard and the medication fridge is monitored to ensure that the medication is stored at the correct temperatures remains in good condition. There registered person should ensure that staff witness statements are documented and signed where they have DS0000002904.V343984.R01.S.doc Version 5.2 Page 27 3 OP9 4 OP16 Carisbrooke Manor been part of a compliant investigation. Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Carisbrooke Manor DS0000002904.V343984.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!