Inspection on 04/10/05 for Carisbrooke Manor

This inspection was carried out on 4th October 2005.

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.

Other inspections for this house

Carisbrooke Manor 19/06/07

Carisbrooke Manor 01/02/06

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 4th October 2005 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.V256181.R01.S.doc Version 5.0 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.V256181.R01.S.doc Version 5.0 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.V256181.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2004 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.V256181.R01.S.doc Version 5.0 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, two catering staff and two care staff who were on duty at the time of the inspection. Throughout the day the Inspector spoke to six people who lived in Carisbrooke Manor and examined recent quality assurance questionnaires from relatives about the care provided. The inspector looked at a range of paperwork in relation to staff rotas, menus, medication records, quality assurance, care plans, accidents, risk assessments, meetings with staff and people who live there, staff training and complaints. 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 including the kitchen area. What the service does well: Many of the staff team had worked at the home for a number of years and knew the people who lived there very well The Inspector noticed that good relationships had developed between the staff, proprietors and residents. The proprietors visited the home regularly and residents spoken to knew their names. There was a loyalty reward system for long serving staff, which consisted of pay enhancements. People spoken to said the meals were very good with choices at each meal and plenty to eat. The home provided bowls of fresh fruit in the lounges for people to help themselves to. The home provides a pleasant environment and was noted to be very clean and tidy. People spoken to said the staff worked very hard to keep it that way. When the home received any complaints they took them seriously and always made sure that they were looked into and addressed. People who lived at the home said they were asked about things in meetings and on questionnaires, such as the type of food they would like to see on the menu, activities and entertainments, suggestions for outings and whether they had any complaints. The home had a good induction and training programme to make sure the staff knew how to care for people. Just recently some of the people who lived at the Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 6 home joined in a fire training session and the manager is looking at other training sessions that people might be interested in, for example, how to look after skin properly and prevent sores. 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 contacting your local CSCI office. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 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.V256181.R01.S.doc Version 5.0 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): 3 The service users had their needs assessed prior to entering the home by the manager and the Care Management Team, when funded by them. EVIDENCE: The home had an admissions policy and procedure that included emergency admissions and this guided practice. The manager completed in-house assessments and there was evidence that assessments and care plans completed by Care Management were obtained by the home prior to admission. The assessments were important as they provided vital information for the care planning stage. The homes assessment documentation covered all the required points highlighted in the standard and the manager had recently updated this to enable more information to be written down. The manager routinely wrote to service users or their representatives following the assessment to state formally the homes ability to meet needs. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 9 The staff members spoken to described that they helped in the admission process by unpacking for people, settling them in, showing them around and introducing them to other service users. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 10 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 and 9 Service users health and social care needs were set out in care plans although more comprehensive recording will provide a fuller picture of the care provided. A proactive approach to liaison with a GP is required in one instance to enhance the provision of medication, as well as meeting the lifestyle choices of a particular service user. 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. Care plans were signed by the person who formulated them and by the service user or their representative on agreement. Risk assessments were in place for all activities deemed to pose a risk and service users spoken to felt their health care needs were met and that staff supported them in a caring way. However it was noted that one service users health had deteriorated recently and they were cared for mainly in bed. They had experienced a weight loss and developed a small pressure sore. The district nurse was involved with support and advice and pressure area care had Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 11 been initiated with two hourly turns and a specialist mattress. Documentation surrounding the care the service user received needed to be more comprehensive to enable the Inspector to obtain a full picture of the care provided. A food-monitoring chart had been started but was stopped several days later and a fluid balance chart did not give clear details of input and output. Daily recordings of care for other service users did not always give a picture of the care provided over a twenty-four hour period. For example an entry that stated, ‘ in bed all shift’, gave no explanation as to why or how often the service user was checked to see if they were ok. 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. 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 two areas of medication management that needed to be addressed, one of which was the area of transcribing the full instructions onto the MAR sheet. The second involved ensuring that one particular service user who liked to sleep late received all their prescribed medication. This may involve a discussion with the GP regarding the times of medication currently on the MAR sheet. The Inspector noted that for three days the particular service user did not receive their morning dose of important prescribed medication. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 12 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): The home maintained community links and encouraged service users to keep in contact with their families. The meals provided in the home were varied, offered choices and ensured a balanced diet. EVIDENCE: Service users spoken to confirmed that their visitors were made to feel welcome and could visit at any time. The home had made links with the local community, for example local churches for religious services and schools gave concerts at certain times of the year. The home had visiting entertainers on a regular basis and produced a newsletter to keep service users, relatives and the local communities up to date with events. Some service users enjoyed shopping at the local superstore. 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. However one feedback card from one service user stated that sometimes the food was not up to standard. The manager is aware Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 13 of this and will try to resolve this particular issue. Fresh fruit and vegetables were used each day. The cook had lists of the service users who required special diets and advised that on admission staff completed a likes and dislikes form that was handed to catering staff to make them aware of any issues. She explained that people were able to suggest changes to the menus via residents meetings, quality circle meetings or just by asking staff. 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. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 14 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 The home provided an atmosphere whereby people feel able to make complaints. EVIDENCE: The homes complaint procedure was clear and displayed in the entrance. 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. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 15 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 and 26 The home provided a comfortable and safe environment for services users and staff. EVIDENCE: The home was well maintained internally and externally. 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 has thirty-one single bedrooms, twenty-one of which are en-suite and six shared rooms, two of which are en-suite. Two of the shared bedrooms are currently being used as single rooms. The central courtyard was safe and housed a water feature and garden furniture. A training/meeting room was currently being 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 reported that sufficient equipment was provided within the home and repairs or replacements made as required. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 16 The home was very clean and tidy and free from any offensive odours in the areas assessed by the Inspector. Service users spoken to were happy with the cleanliness of their rooms. Cleaning schedules were in place and signed by staff as tasks were completed. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 17 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 and 30 The home provided a stable and safe environment for service users by the provision of trained staff in sufficient numbers. EVIDENCE: Staff rotas were examined and showed that there were 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 and had a bank staff rota for assistance during holidays and sickness and increases in service user dependency. There appeared to be sufficient domestic and catering staff and the home employed an activity coordinator for two hours a day five days a week. 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. 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 Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 18 assessment, handling complaints, quality assurance, understanding osteoarthritis and catheter care, and ongoing mandatory training updates in fire, moving and handling and basic food hygiene. Nine staff have completed a first aid course. Staff also watched videos on dementia awareness and crosscultural care. All seniors and fourteen care staff had completed an accredited medication course with a further eight staff due to start on the next course in January and all staff had completed adult protection training. The manager and the training and development manager were due to attend the next local authority adult protection session. Ten staff had completed NVQ Level 2 with a further eight progressing and one staff was progressing through Level 3 with a further two awaiting enrolment onto the course. The manager had completed NVQ Level 4 and the Registered Managers Award and the assistant manager was progressing through NVQ Level 4. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 19 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, 32 and 38 Service users health, safety and welfare were promoted by an open and inclusive style of management within the home and by the proprietors. 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 thirteen years, initially as a senior carer then an assistant manager for eleven years until taking her current post six months ago. She had completed risk assessment training and is investigating further management courses. Via discussions the manager demonstrated a proactive approach to training, service user consultation and inclusion and promotion of quality within the home. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 20 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 manager described to the Inspector a recent fire prevention training event for staff, which was opened up for service users to attend. Several attended and appeared to enjoy the training so much that she has discussed extending other training events with them and relatives. The proprietors visited the home a couple of times a week and met for 1-1 discussions on a monthly basis with the manager for support and advice. Each month the managers of the three homes and the proprietors met to discuss issues and shared good practice within the homes. The proprietors completed monthly visits under Regulation 26 of the Care Homes Regulations and produced a report for the CSCI. The manager ensured that equipment was repaired and serviced regularly, staff members were appropriately trained, fire equipment was tested and staff 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. Requirements from the last inspection had been met. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 21 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 x x x x x 3 Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 22 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 OP8 Regulation 12(1)(a) Requirement The registered person must ensure that daily recording accurately reflects the care provided over 24hours. The registered person must ensure that liaison is made with a specific service users GP regarding alternative times of medication to fit in with their lifestyle choices. The registered person must ensure that when transcribing medication, staff write the full manufacturers instructions. Timescale for action 05/10/05 2 OP9 13(2) 05/10/05 3 OP9 13(2) 05/10/05 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 OP28 Good Practice Recommendations The home should continue to work towards 50 of care staff trained to NVQ level 2. Carisbrooke Manor DS0000002904.V256181.R01.S.doc Version 5.0 Page 23 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.V256181.R01.S.doc Version 5.0 Page 24 - 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. 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