CARE HOMES FOR OLDER PEOPLE
Carleton Court 108 Carleton Road Pontefract West Yorks WF8 3NQ Lead Inspector
Tony Railton Unannounced Inspection 18th November 2005 09:00 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 Carleton Court DS0000006170.V264498.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. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Carleton Court Address 108 Carleton Road Pontefract West Yorks WF8 3NQ 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) 01977 702635 01977 701108 Carleton Court Care Limited Mr Rodney Walker Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th May 2005 Brief Description of the Service: Carleton Court continues to provide accommodation and personal care for 25 people over the age of sixty five. Set back in its own grounds Carleton Court has a large drive with parking to the front and a very large walled garden to the rear. There is a large reception through the main entrance at the front which leads to the office, dining rooms, lounges and bedrooms. There is a passenger lift provided along with assisted bathing for those who require them. Most of the accommodation provided is single , however, there are two very large bedrooms for those who wish to share. Regular activities are organised including outings, tips to the theatre and eating out. The care provided by the home is based on ordinary living principles and residents are encouraged and supported to do as much for themselves as possible and maintain their independence. The home is run on Christian values and there are regular services held in the home by clergy from different denominations. The home is situated on a main bus route and there are local shops nearby. Pontefract town centre and all services and amenities are only a few minutes journey from the home as are the M1/M62 link roads. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 08.30 to give the inspector the opportunity to observe the morning routines in the home. This was a particularly positive and enjoyable inspection and it was noted that the home continues to meet all statutory requirements and nearly all the minimum standards. After talking to residents, a relative, the assistant manger, senior care worker and other staff and examination of the homes documentation and through observation a number of improvements were noted. The inspector would like to take the opportunity to thank everyone for their hospitality and co-operation throughout the inspection. It was noted that a resident of the home has recently been presented with a Benson Medal and a Fellowship of the Royal Society of Literature in recognition of a lifetimes writing of outstanding literary merit. The assistant manager said it was a fantastic occasion which was enjoyed by everyone. What the service does well: What has improved since the last inspection?
It was noted that 99 of care staff now have a National Vocational Qualification at Level 2 or above. The staff training records show that care staff
Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 6 also receive training in how to care for older people with challenging behaviour, caring for people who have Dementia and in Palliative Care. The assistant manager said that staff training has a high profile and there is a commitment to provide care staff with the training they require to do their job properly. On the day of the inspection care staff appeared to be confident and competent and were comfortable explaining their work to the inspector. Upon inspection it was noted that two bedrooms and one of the lounges have been decorated. It was also noted that the kitchen has also been decorated. All areas of the home are decorated and maintained to a good standard. It was also noted that the home now provides a new specialist hydraulic bed to assist with the care of one resident. The home has also helped in securing a custom built wheelchair for another resident with mobility problems. These actions are to be commended. The record of activities has improved with the use of descriptive words to shown and reflect residents’ choices, preferences, likes and dislikes. Discussion with the assistant manager suggests that the daily records may also benefit from an increase in the use of descriptive words. 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. Carleton Court DS0000006170.V264498.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 Carleton Court DS0000006170.V264498.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&6 No residents are admitted to the home without first having their personal and healthcare needs assessed. EVIDENCE: Residents case files show that all residents have a comprehensive assessment of their personal and healthcare needs before they are admitted. The homes assessments are good and show residents choices and preferences. Some residents are admitted already having a Care Management Programme Assessment carried out by the local authority. The home does not provide specialist intermediate care or equipment for intensive rehabilitation. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Residents’ health, personal and social care needs are set out in their individual plans and they are assisted and supported to make decisions about their daily lives. EVIDENCE: Discussion with residents, their relative, care staff and examination of residents case files show that their care and health needs are met by the home. Examination of residents’ medical records including medicine administration records, G.P and District Nurse visits show that residents’ healthcare needs are monitored on a regular basis. Discussion with residents, inspection of the comments book, quality assurance report and through observation it was established that residents are happy with the care provided by the home and that residents are treated with dignity and respect at all times. It was noted that one entry dated 2005 in the comments book was by a local general practitioner who was very complementary about the quality of care and high standards set by the home. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Residents find that the lifestyle experienced in the home matches their expectations, preferences, and satisfies their social, cultural, religious and recreational interests. EVIDENCE: The diary of activities is written in such a way as to show what activity was chosen by residents’ and who was asked if they wanted to participate and who chose not to take part. This standard of recording is very good indeed and care staff are to be commended for their efforts in maintaining such a good standard of recording. The assistant manager said that residents are encouraged and assisted to make decisions about their lives. One relative said that she is always made to feel welcome and that she can visit at any reasonable time. Residents spoken to said that the meals are great and that they have a choice of menu. Discussion with the assistant manager indicated that following a recent Food Hygiene Inspection the home has been nominated for a Silver Award because of the high standards of cleanliness in the kitchen, staff training and the quality of food provided. This standard is to be commended. The registered manager / owner and all the staff team, and in particular kitchen staff, are to be commended for their efforts in maintaining such good standard of meals and meal preparation within the home.
Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 11 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): 16,17 & 18 Residents and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Examination of the complaints book and pre-inspection questionnaire and through discussion with the assistant manager shows that the home has received one complaint since the last inspection. It also shows that the complaint was appropriately dealt with. The quality assurance questionnaire report shows that the majority of residents and their relatives know how to make a complaint. The inspector was pleased to note that the home as a copy of the Wakefield Social Services and Health Multidisciplinary Adult Abuse and Protection Policy and Procedure which forms part of the training for all staff. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 12 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): 19,22 & 26 Residents live in a safe, well maintained environment and also have access to safe and comfortable indoor and outdoor communal facilities. EVIDENCE: Inspection of the home showed that all parts of the home are decorated to a good standard and well maintained. Through inspection and discussion with residents and care staff it was found that residents bedrooms are personalised and comfortable. Residents appeared to be happy with their rooms with most surrounded by their own possessions. The assistant manager showed the inspector a specialist bed and custom built wheelchair that had been secured by the home to help care for one resident. It was noted that a few bedrooms, a lounge and the kitchen had been decorated since the last inspection. It was also noted that the kitchen has been nominated for a Silver Award following an inspection by the Food Hygiene department, this was specifically for the good standards of cleanliness, the good quality of food and staff training. ( see Standard 15)
Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 13 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): 27,28,29 & 30 Residents’ needs are met by the numbers and skill mix of staff, and they are in safe hands at all times. Residents are also protected by the homes staff selection and recruitment policies, procedures and practices. EVIDENCE: Discussion with the assistant manager and examination of the staff training records show that 99 of staff have a National Vocational Qualification Level 2 or above. This is commendable and is over and above the 50 ratio recommended by minimum standards. Staff recruitment records show that appropriate checks, including CRB check and references are taken up before new staff are employed. The inspector was also pleased to note that there is a training and development programme for all staff with additional training identified such as Dementia and Palliative Care. This standard is also to be commended. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 14 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): 31,32,33,35 & 38 Residents 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. Residents also benefit and take advantage of the ethos, leadership and management approach of the home. EVIDENCE: Through discussion with residents, their relatives, care staff and assistant manager, examination of the homes records, and through inspection and observation it was found that the home is run for the benefit of residents. The inspector was impressed on the day of the inspection with the standards of care and in particular the relaxed and inclusive atmosphere created in the home. Everyone’s efforts are to be commended for maintaining such a good homely, comfortable and positive environment. Discussion with the assistant manager and examination of planned supervision list show that residents’ benefit from been cared for by appropriately supervised staff.
Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 15 Discussion with the assistant manager, care staff and examination of staff training records and inspection showed that the health, safety and welfare of residents and staff are promoted and protected. Other records show that the best interests of residents are safeguarded and protected by the homes policies procedures and practices. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 16 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 3 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 3 18 3 3 X X 3 X X x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 3 X 3 X X 3 Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 YA33 Good Practice Recommendations The manager should have a National Vocational Qualification Level 4. Carleton Court DS0000006170.V264498.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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