Inspection on 25/08/05 for Carlene House

This inspection was carried out on 25th August 2005.

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

Carlene House 27/03/07

Carlene House 02/12/05

Carlene House 14/12/04

Carlene House 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Carlene House 17 Woodcote Valley Road Purley Surrey CR3 3AL Lead Inspector Claire Taylor Announced 25 August 2005, 16:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Carlene House Address 17 Woodcote Valley Road, Purley, Surrey, CR3 3AL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8668 7676 020 8669 6041 marcel@fircroftservices.co.uk Fircroft Services Limited Mrs June F Woodrow Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14 December 2004 Brief Description of the Service: Carlene House is a detached care home for ten adults with learning disabilities, aged between 18 years and 65 years. Situated in a quiet residential area of Purley, the home is well placed to access local transport links, amenities and resources. The home consists of ten single bedrooms, a good-sized lounge and dining area with an activities room on the second floor. The kitchen is spacious and there is a laundry room on the ground floor. Access to the first and second floors of the home is via a set of stairs. There are sufficient numbers of bathroom/shower and toilet facilities located throughout the home to meet the service users needs. The large landscaped garden is set out over two levels, with a raised lawn and patio area equipped with tables and chairs and barbecue facility. All service users attend day services and employment and the home offers a varied and structured programme of activities and outings. The home does not provide its own transport but supports service users to fully access various public transport services. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit lasted four hours and took place during late afternoon and early evening. Six of the service users met with the inspector, three were away on a holiday and one was with family. All the service users met were willing to share their experiences about life at the home and their help with this inspection is very much appreciated. Time was spent examining records, talking with service users and two staff on duty. The registered manager also arrived at the home and is thanked for her time to facilitate this unannounced inspection. A brief tour of the premises took place and three service users showed the inspector their bedrooms for which they are thanked for taking the time to do so. Prior to this inspection, six service users, supported by their key staff or relative, completed a questionnaire about their life in the home and eight relatives used the Commission ‘s pre inspection comment card to express their views. All those involved are thanked for their cooperation and the service users and staff for the hospitality shown throughout the inspection process. What the service does well: This is a home where the people who live there are well cared for and their views and choice of lifestyle are foremost to the home’s stated purpose. It has a competent and stable staff team who understand the needs of the young adults living there. Management of the home is very well ordered with the benefit of a staff team that remains largely unchanged resulting in stability and familiarity for the service users. Time was spent independently and informally with individual service users who gave favourable comments about the home and also remarked highly of the staff team and services provided at Carlene House. Staff put a lot of effort into arranging entertainment and organising activities and those service users met, spoke of good frequency and quality of outings. They were also complimentary about the good food, caring staff and that they were happy at this home. Planning and review of care is thorough and helps the service users build upon and develop their independence as far as possible. Care plans are clearly recorded, highlight achievements and progress and are routinely shared with the service users involved. The manager retains good communication links with the service users’ relatives and representatives. Comment cards received prior to the inspection were also very positive. One relative described the home as “well managed and excellent in all respects”. “Carlene House is a home to its residents with marvellous caring staff “said another. Another commented, “We continue to be very well satisfied with the care offered by the home and especially the manager, Mrs June Woodrow.” Additionally, three relatives stated that their family member was “very happy” at Carlene House. The home is kept clean, safe, decorated to a very high standard and provides comfortable surroundings for the people who live there. Management take Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 6 action to ensure that any repairs or necessary maintenance are dealt with promptly. The home once again shows consistency in its application of the National Minimum Standards and is again commended for exceeding some standards, specifically in relation to service users activities and quality monitoring systems. 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. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Accessible information is in place that describes the services provided. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission and that staff are aware of how to support them. EVIDENCE: The majority of service users have lived at the home for many years with the last admission taking place in June 2003. Service users’ files were randomly sampled and record keeping continues to be well organised. Needs assessments had been reviewed within a six-month timescale in conjunction with the service users’ respective care plans. Content of the assessments was detailed and person centred to the service user’s individual needs. Files sampled also indicated that care managers assess their service users needs on an annual basis. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Service users’ plans of care clearly identify their needs and how they are supported to achieve their planned goals. Individual plans are frequently reviewed and reflect any changing needs. Choice and decision making for service users is promoted to a high standard enabling their involvement and opportunities to contribute to the operation of the home. EVIDENCE: All service users have a PCP (Person Centred Plan), which identifies individual aims and goals as well as their achievements that are all based upon their respective needs assessments. This tells the service user and everyone else who supports them what the plan for their future is and how this will be made to happen. The PCP can change when a service user wants different things and if there are other things that change in their life. Records showed that service users and their families are fully involved with the care planning process and their key staff regularly review individual plans. Care plans are updated on a monthly basis and main reviews take place annually to ensure that any changing needs are identified and addressed. The service users’ PCPs have been supplemented with pictures to make them more accessible for those who cannot read. The manager added that there are future plans to format them further with personalised health action plan books known as a “My Health” Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 10 booklet. The move to person centred planning is seen as good practice as this is a more resident focused way of working. The risk taking process is well managed. Potential risks and hazards, specific to each service users’ assessed needs are well written and reviewed on a regular basis. Service users are encouraged to learn about personal safety issues such as community travel and cooking. A risk assessment tells the people that support the service user if there are activities that a person undertakes, or things that might happen, that put them at risk of being harmed. If there are any risks, assessments also tell staff about what they can do to try to prevent a service user from being harmed. There are formalised opportunities for service users to participate in group discussions/ meetings about the operation of the home. Minutes of service users meetings are regularly held and discussions are geared towards their views. E.g. choice of activities and menus. Staff appeared committed to ensure that service users are fully involved with the operation of the home and encourage them to contribute. Service users appeared comfortable, and staff members have clearly established positive and cooperative relationships with each individual. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 and 17 Service users benefit from an excellent choice of recreational activities both within and outside of the home that are organised around their individual preferences. The daily routines and house rules promote service users’ rights and encourage independence. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. Dietary needs are catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are provided with guidance and support to make use of facilities appropriate to their interests and needs. The home informs service users about activities via meetings, informal discussions and the use of a notice board. The service users access a wide range of community activities and resources for which the home is commended. These include swimming, Sutton Mencap, Rangers, bingo, horse riding, social evenings and local pubs and restaurants. The female service users attend the Disabled Rangers Group of the Guides and three were away on a holiday organised by the group during this visit. Each service user possesses a bus pass and regularly uses public transport services Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 12 including bus, tram and train. The home has a separate activity room and offers a wide range of in house entertainment facilities such as television, videos, music system, art and craft activities and jigsaws, computer and board games. During the inspection, service users were busy and occupied with activities. E.g. jigsaws, drawing and assisting with meal preparation. Staff interaction also showed that the carers were mindful of how they addressed service users, and they were seen to be polite and friendly. Annual holidays are supported by the home, which pay for staffing costs. The current service user group generally choose to go away together and were looking forward to their forthcoming holiday to Spain. The home circulates a list of planned activities chosen by the service users. In view of the wide range of activities provided and excellent standard of record keeping, this standard has been assessed as exceeded on this occasion. Records showed that service users often engage with friends outside of the home as well as friends and colleagues being welcomed to Carlene House. Satisfaction questionnaires are provided by the home to relatives and families. Responses gave very positive views about the care given, that they were warmly welcomed at the home, and clearly felt actively involved with their respective family member. Menus are written in conjunction with the service users, based on their likes and dislikes. A copy of the current menu is displayed in the kitchen. The meals offered by the home are varied, nutritious and the service users spoken to confirmed that they enjoy the meals and can choose alternative dishes if they prefer. Service users had their evening meal during this inspection and staff were available throughout to provide appropriate support. The atmosphere was relaxed and sociable for both service users and staff. The manager explained that main food shopping for the home is ordered and delivered weekly via the Internet. Although service users sometimes shop for smaller food provisions, the manager agreed to discuss the issue with the service users at their next meeting to establish whether they would prefer to go to a supermarket for their weekly food shop. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 Promotion of health is well observed. Service users welfare is closely monitored to ensure that their physical and emotional needs are met. Medication is well managed to maintain maximised good health. EVIDENCE: The home’s philosophy of care emphasises that service users are supported to maximise independence and control over their lives as far as possible. This is clearly reflected within the home’s stated purpose and service users’ personal files. Through observation and discussion with staff, it was clear that daily routines and house rules promote independence and individual choice for service users. Staff were observed to interact and communicate with service users in a respectful and sensitive manner. The home encourages service users to be responsible for housekeeping tasks, which is specified in their care plans and an “independent living skills rota”. Two service users were supported to prepare themselves a hot drink and help with meal preparation. Records examined confirmed that arrangements were in place for meeting healthcare needs. “Health plan” record sheets for each service user are in place and as mentioned previously, the manager plans to complete health books for each service user that will provide a more detailed profile of health needs. Information about health conditions such as epilepsy is available in the home. Staff have received training on epilepsy to enable them to fully support those service users with such specialist needs. Access to other NHS facilities is Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 14 available and plans include detail of GP involvement as well as Consultant, dental, chiropodist, optician and physiotherapy services. These systems are good examples of assurance that healthcare needs are being met and monitored appropriately. The home operates clear policies for the receipt, recording, storage, handling, administration and disposal of medicines including one on the use of homely remedies. One service user self medicates and an appropriate risk plan was in place. Medication is supplied in a blister pack from a local pharmacy and is kept securely in a locked cabinet in the office. A list of all staff authorised to sign for medication is maintained and administration sheets were noted to be accurate. Staff have undertaken medication training provided by the home’s pharmacist. The home receives three monthly audits from the pharmacist to further ensure medication is managed appropriately. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. EVIDENCE: The home has a complaints policy, which is also provided in a user-friendly format, copies of which are displayed throughout the home. (E.g. pictures and symbols for those service users who have limited expressive speech). There is a complaints book and records showed that no complaints have been made since the last inspection. Service users who spoke with the inspector were clear about who they would speak to if they felt unhappy or worried about something. They are provided with a summary complaints procedure. Likewise, feedback from relatives showed confidence that the home would deal with any complaints appropriately and that staff are approachable and receptive to any concerns raised. The home maintains accurate records of any incidents or accidents. There are also detailed policies and procedures in place regarding the protection of vulnerable adults. The manager organises training on adult protection issues for the staff having attended a three-day course run by the local authority. Records confirmed that any new staff are properly inducted on abuse awareness and policies and procedures regarding the protection of vulnerable adults. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26 and 30 Carlene House is homely, clean, furnished and decorated to a high standard, thus providing the service users with safe, comfortable surroundings to meet their needs and emotional well-being. Bedrooms are designed and furnished to meet the personal preferences and individual lifestyles of the service users. EVIDENCE: The home is well positioned to access local transport, amenities and relevant support services. The communal areas, bathroom / toilet facilities and five of the bedrooms were viewed on this occasion. The décor appears modern, bright and in keeping with the service users’ individual and collective needs. There are many “homely” touches around the premises such as the service users’ artwork creations and photographs of family and friends and social events such as holidays and parties. The registered provider is vigilant over general maintenance of the premises and ensures that repairs and upkeep of the building are undertaken. Well-kept records for the ongoing maintenance and redecoration of the premises are in place. Three service users showed the inspector their bedrooms and commented that they were happy with them. Service users have personalised their rooms with family photographs, ornaments, music centres, televisions, cds and videos. The standard of cleanliness and hygiene throughout Carlene House was observed to be very Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 17 high. The home has various policies and procedures on hygiene and infection control and staff have received mandatory training in key areas. To enhance independence, staff encourage the service users to take responsibility for their own rooms and participate in household cleaning tasks on a daily basis. Detailed care plans reflect this and the home’s independent living skills rota makes clear reference to the daily tasks of the service users. The home has not had an inspection from the Environmental Health Department since February 2003 and as good practice, this should be arranged to ensure that the premises comply with current legislation and requirements. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 There is a competent and well-trained staff team who clearly understand the needs of the young adults living there. The manager and most of the staff have worked in the home for a number of years resulting in stability and familiarity for the service users. Overall, recruitment practices are securely managed to maximise protection for the service users although new CRB checks must be obtained for any new employees. EVIDENCE: Since the last inspection, there has been little change to the staff team resulting in ongoing stability and beneficial continuity of care for the service users. Allocation of staff allows for one to two per shift with extra staff deployed according to service users needs and activities. Regular staff meetings are held on a monthly basis and in depth consultations about the home’s care practices and service users needs are routinely discussed. Staff files were well organised and contained all the required documentation to evidence their fitness to work with this service user group as well as training certificates. Induction processes ensure that staff are fully inducted in all aspects of the home’s care practices along with some training relevant to service users needs e.g. Epilepsy and Makaton signing. The home keeps records which show what training courses staff have done, and when they did them. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 19 Relevant literature is available concerning any conditions that are associated with service users specific needs. E.g. Cerebral Palsy and Down’s syndrome. All new staff who commence work in the home undergo a thorough vetting procedure to ensure that they are fit to work with vulnerable adults. Since the last inspection the home has employed two members of staff; both files were examined and contained the majority of required checks including a completed job application, the terms and conditions of their employment, two references, proof of identity and a CRB disclosure/POVA check. However, one CRB check had been completed by the staff’s previous employer and such checks are not transferable. The registered manager must therefore ensure that an up to date CRB and POVA check for any future employees is obtained before they commence work. Records checked confirmed that the staff concerned was not working unsupervised however. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Service users and family members have good opportunities for becoming involved in decision making in the home. The manager and staff team show vigilance to improve the service and meet any concerns raised by service users. The home is commended for ensuring that quality of care is regularly appraised so that it can recognise where standards may have fallen and take action to resolve any issues. The home provides a safe, well-maintained environment to ensure that service users health, safety and welfare is promoted and protected. EVIDENCE: A range of quality assurance systems are used to measure the success of how the home is achieving its aims and serve the best interests of the people who live there. Examples include care plan reviews, meetings, monthly visits from the registered provider and a quality action plan that is based on the service users opinions. In addition, satisfaction questionnaires are provided for service users, their relatives and other relevant professionals. The manager and the registered provider review the information gathered from the questionnaires. Four relatives’ meetings are held each year as well as regular meetings for the Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 21 service users and staff to discuss issues about the home and significant events. Records seen indicated very positive views about the home and care received and it was evident that effective communication processes are in place to ensure that quality management systems are upheld in the home. Likewise, the Commission received favourable comments prior to the inspection. The manager and staff are commended for their hard work to ensure that quality of care is regularly appraised, hence the marking of 4 on this occasion. The home is good at making sure that the premises is kept in a good state of repair and health and safety guidelines are well observed. Records seen confirmed that good systems are in place to ensure the health, safety and welfare of the service users is consistently monitored and any issues were being dealt with as necessary. Regular fire drills were being carried out and risk assessments covering safe working practices have been completed for the premises and individual service users. Certificates showed that staff had received training in key topics i.e. infection control, food hygiene, fire and manual handling. Any accidents or incidents are recorded appropriately in a book and are reported where necessary and in accordance with regulation 37 of the Care Standards Act. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 4 4 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carlene House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 23 No Are there any outstanding requirements from the last inspection? 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 34 Regulation 17(2) sch.4(6)1 9(1)(b,c)S ch.2 (6 & 7) Requirement The registered provider must ensure that they obtain an up to date CRB and POVA check for new staff before they commence employment. Timescale for action From receipt of this report and henceforth 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 24 Good Practice Recommendations The home has not had an inspection from the Environmental Health Department since February 2003 and this should be arranged to ensure that the premises comply with current legislation and requirements. Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 8th Floor, Grosvenor House 125 High Street Croydon CR0 9XP 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 Carlene House G53-G53 S25762 carlenehouse V180096 250805 stage 4.doc Version 1.30 Page 25 - 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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