Inspection on 05/04/07 for Carleton Court

This inspection was carried out on 5th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Carleton Court 18/11/05

Carleton Court 26/05/05

Carleton Court 17/11/04

Carleton Court 02/06/04

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 Carleton Court 108 Carleton Road Pontefract West Yorks WF8 3NQ Lead Inspector Susan Vardaxi Unannounced Inspection 5 April 2007 9:10 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.V328146.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. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 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 690744 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.V328146.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 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 support. Most of the accommodation provided is in single bedrooms, 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 the people who live there 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. The fees charged in April 2007 were from £366 to £370; hairdressing, chiropody and newspapers/magazines are charged in addition to the fees. The Provider gives a service user guide to enquirers at initial contact. This provides information about the service and the role of the commission. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit completed on the 5th April 2007 over eight hours and a visit by a commission pharmacist inspector occurred on the 26 April 2007 and lasted 5 hours. The visits included talking with the people who live at the home, four relatives, 5 staff, the manager and two visiting district nurses. Some records were inspected and a tour of the building completed. Some surveys forms were sent to service users, their relatives and health workers to obtain their views of the service. Fifteen survey comment forms were completed and returned to the Commission. Staff at the home have made appropriate notifications to the commission; including safeguarding referrals they have made in respect of concerns they had about the handling of peoples finances by an external source. The inspector would like to thank the people who live at the home their relatives/representative and all who participated with the overall inspection process for their co-operation What the service does well: Information provided by the people who live at the home and their relatives on survey comment forms received were discussed at the time of the visit and showed that people had been given enough information about the home prior to admission, and were generally satisfied with the care and support received. Comments made included people are “kept informed if GP is needed”. “Staff are involved in health management”. “Staff always have time to talk to the people”. “Staff always friendly and helpful” “most staff listen and act on what the people say and are available when needed”. “Can’t fault staff”. Two members of staff spoken with said they are “very well supported by management, who are very approachable” another also said “ the management think a lot about the people who live here.” Activities are provided and were considered to be adequate and the local clergy visits regularly. All the people spoken with made positive comments about the meals, the home have been awarded the local authority’s Gold Award for the provision of foods. At the visit the home was seen to be clean and decorated to a good standard. A rolling programme of refurbishment and decoration is in place. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 6 The relatives/representatives survey comment forms showed that they are made to feel welcome when they visit, are consulted about their relatives care and comments made in respect of staff were good. All said they would know how to make a complaint if necessary. Staffing levels were considered to be adequate from information obtained from staff spoken with and the rosters seen and Staff training is provided on an ongoing basis. What has improved since the last inspection? What they could do better: Generally the home is run and managed to a good standard and in the best interests of the people who live there. Care plans have been developed for all the people at the home and include assessed needs, however some require development as they do not always include the action needed by staff to meet some peoples needs. The manager said he had tried without success to meet the local pharmacist and primary care trust (PCT) to discuss and improve some practices regarding medicines and recording, and the commissions pharmacist inspector visited to consider processes and advise the manager in improving medication recording, audit trails and arrangements. Currently there are no emergency call points in the lounges and this could lead to people experiencing difficulty in contacting staff, when staff are not in the lounges, although the manager said a new emergency call system is to be installed throughout the home. Staff records seen for those recently employed at the home showed that CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks had not been completed by the home, therefore the people living at the home are not currently fully supported and protected by the homes recruitments procedures. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 7 The laundry room has paint peeling from the concrete floor and walls making it difficult to wash the walls and presenting a risk of cross infections occurring from water collecting on the concrete floor. 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. The summary of this inspection report can be made available in other formats on request. Carleton Court DS0000006170.V328146.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 Carleton Court DS0000006170.V328146.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): 3,6 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are assessed prior to their admission to the home and information is provided to enable them to make an informed choice about living in the home. EVIDENCE: Copies of service users guide were seen displayed in the home. The homes contract has recently been reviewed and provides people with satisfactory information. A relative said he was given a copy of the service user guide and contract and had seen CSCI report. The report was displayed on the notice board in the seating area at the entrance of the home. The relative said his father had spent a day at the home before making a decision to live at the home. A copy of the care manager’s pre admission assessment and a local authority care management assessment was seen on the file of a person who resides at the home. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 10 Intermediate care is not provided at the home. Carleton Court DS0000006170.V328146.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): 7,8,9,10 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Care plans are in place and reviewed, although some need to provide fuller detail to ensure staff action to meet peoples’ needs is clear. People generally receive the healthcare and medicines they need but some action is needed to improve medication processes. EVIDENCE: Survey comment forms returned showed that people were generally satisfied with the care provided. Comments included “ staff are prompt in recognising a medical problem and gets medical help if needed”. “Kept informed if GP etc is needed”. “Staff are involved in health management”. There were no incidences seen during the visit that could have affected peoples privacy and dignity, however the information on one of the fifteen comment forms stated that they would like to see their relative in the privacy of their bedroom. Relatives spoken with at the visit were satisfied with the care provided. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 12 A relative said they were aware of their relative’s care plan, which was discussed with them regularly. All people living at the home have care plans, which had been reviewed, and risk assessments had been completed. There was discussion with the manager about some care plans not fully detailing action to be taken by staff, e.g. the action needed by staff to orientate a person who has dementia to the environment, the time and place, and for someone who was assessed as being at risk as they could not use the emergency call. Records of GP and other health professionals’ visits were seen. Records of the people who live at the home weights had been recorded and nutritional care plans completed, however nutritional assessments had not been documented. A GP who took part in the pre visit survey did not have any concerns and considered that the home provides a varied & supportive environment and staff had always responded appropriately to medical issues. Two district nurses spoken with said the staff contact them straight away if there are any problems and no one has pressure sores. The local pharmacist had not put the names of people on the pharmacy labels for a medication provided in sachets making it necessary for staff to write the service users name on the boxes. The manager said he had been trying to meet with the local pharmacist and had approached the PCT about advice and assistance in relation to improving medication administration records (MAR). There were no signature omissions on the medication records seen, however the discussion with the manager about the issues of MAR, medication balances, and some processes led to a visit by a commission’s pharmacist inspector. The Commission’s pharmacist inspector visited the home on the 26 April. The reason for this visit was to undertake a pharmacist inspection of the service to look at arrangements within the home that support the safe handling of people’s medicines. The visit lasted 5 hours and involved looking at medicine records, storage and administration. During the visit the pharmacy inspector spoke to the manager, deputy manager, a senior member of staff and four people. Overall it was found that people who use the service experience good outcomes in the area of medicines management. This judgement has been made using available evidence including a visit to this service. There are robust systems in place in the majority of areas of medication handling and recording. This means that people are getting their medication as prescribed and their health and wellbeing is being maintained. There is a medicines policy in place. The policy needs to be updated to include the changes to the supply of oxygen, the recording of fridge temperatures and the disposal of medicines. These activities are currently taking place in the Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 13 home but the policy does not reflect this. There is a section headed ‘Drugs brought to Carleton Court by residents’ however there is nothing contained in the section relevant to the heading. The current Medicines Administration Record (MAR) chart was looked at. The pharmacy has recently changed how the charts are printed. There were a number of concerns about the new system. There is no facility to produce blank charts, there was inconsistency in the printing of dosage times and some MAR entries were printed twice. The manager has produced some blank charts to use when required. The pharmacist inspector advised the manager to contact the pharmacy and ask for a MAR chart to be sent with medication when possible. The manager has used the old charts and information from the pharmacy to handwrite the dose times. The pharmacist inspector advised the manager to report the lack of printed dosage times and duplicated entries to the pharmacy to make sure that the next month’s charts are correct. The provision of poorly printed charts means there is a risk that medication may not be administered correctly. Systems have been put in place since the visit on 5 April to improve record keeping. There is a list of staff authorised to administer medication and examples of their signatures. This means that it is possible to identify who was involved if an error was to occur. There are dividers between the MAR charts with people’s names and photographs on. This reduces the risk of mixing up people’s charts and possibly administering the wrong medication. The recording of administration was good there were few gaps. Handwritten entries were kept to a minimum and accurately completed. Cancelled or amended entries were missing the date the change was authorised. It is important to have an accurate record on the MAR of any changes to medication to make sure it is in accordance with the prescriber’s instructions. There was some confusion in the use of codes to record no administration. The code N was used for not required but the definition on the chart was nausea and vomiting. The inspector advised that the code O could be used and a definition recorded on the bottom of the chart. This makes sure that there is an accurate record of why medication was not administered and provides information for the prescriber if a review is taking place. A number of medications used for sedation had dosages of when required for agitation. The pharmacist inspector was informed that the decision to administer was taken after staff had consulted the manager. The pharmacist inspector advised that the prescriber should provide clear information on when to administer medication for staff to be able to make a judgement on the person’s condition at that time. Such information should be recorded in the care plan for all staff to have reference to. An angina spray for one person was located in the cupboard but there was no MAR chart entry. It is important that all medication currently prescribed is Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 14 listed on the MAR even if it is not regularly administered. The care plan for this person also needs to be updated to detail when and how to administer the spray. A record of medicines returned to the pharmacy is kept. This means there is a complete record of medication entering and leaving the home. Medicines are stored securely in locked cupboards and a trolley within the office. At the time of the inspection the office temperature was warm. The pharmacist inspector advised that a regular check of the room temperature would make sure that medicines are being stored at the temperatures recommended by the manufacturers. The fridge in the office is suitable for use and the temperatures are regularly checked. This means that medicines in the fridge are being kept at the correct temperature and are safe to use. Dates of opening of eye drops was recorded, this means that the medication will not be administered beyond the time recommended by the manufacturer. There was a bottle of liquid in the trolley that had a date of use of 3 months from opening. The date was not recorded but the dose was for 1 month. The pharmacist inspector advised that it is good practice to check medication received to make sure there is not a short time of use once opened. The controlled drugs cupboard and register are appropriate. The morning and lunchtime rounds were observed. Only senior staff have responsibility for administration. A system has been developed by the manager to make sure staff administering medication are not disturbed. This is an example of good practice as it reduces the risk of errors occurring because of distractions whilst doing the rounds. Pots were used to hand medication to the person and water was offered to help with the taking of medicines. The pharmacist inspector was advised that the manager had assessed one person that morning for self-administration of an asthma inhaler. The manager was yet to detail the assessment in the care plan. The pharmacist inspector was advised that there is secure storage available in the person’s room for this medication. Since the inspection on 5 April the manager has developed a system to record the remaining balances of medication that is supplied in original packs and prescribed as when required or with doses of 1 or 2. This has been developed to address the problem of discrepancies in the balances of analgesics and sachets. This is an example of good practice as it makes sure the there is an accurate record of medication received and administered, it also helps to make sure there is enough stock. The pharmacist inspector checked the balances from 6 MAR charts and found them all to be correct. An audit of current stock and records showed that medication had been signed for and administered according to the MAR chart. The pharmacist inspector was advised that the prescriptions do not come to the home for checking before the medication is supplied. It is important that Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 15 the person responsible for ordering medication checks the prescriptions to make sure that any changes from the previous month are on the new prescriptions, to check for missing items on the prescriptions and to inform the pharmacy of prescription items not requested and therefore helping to reduce excess stock. The checking of prescriptions is an important part of the management of medication. The pharmacist inspector was advised that all staff have completed NVQ training and ongoing training including medication management was taking place. Since the visit on 5 April the manager has arranged for senior staff to regularly meet. This means there is an opportunity for all staff involved in medicine administration to meet and discuss issues. This is good practice as this means that problems can be addressed as they occur. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 16 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): 12,13,14,15 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s social, recreational interests, cultural and religious needs are met and their choices and preferences are respected and encouraged. EVIDENCE: Some survey comment forms included “activities are usually enough”, “entertainment is done frequently. “Have the choice not to take part in activities”, “good amount of activities” Care plans seen included personal preferences, and showed choices are respected. Relatives comment cards, and relatives spoken with, showed that they are consulted about people’s care. Comments included “staff always have time to talk to residents”. Easter bonnets were seen throughout the home waiting for the parade planned to take place on Easter Sunday. The people spoken with said they had helped to make the bonnets. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 17 Information provided by the manager prior to the visit-recorded activities of; exercise, bingo, dominos, card games, movie afternoons. Organist and church services are held every 2 weeks, and any activity people request is provided within reason. Outings had included visits to a tea dance and shopping centres, walks into Carleton, a visit to the Sculpture Park and out for lunch. The recording of the times people chose to get up in the morning were seen in some care plans and people spoken with had varied views about this, but no one indicated that they had not wanted to get up at the time this happened. It was observed that most people were up and breakfast had occurred when the visit began at 9.10am. Three staff spoken with said that most service users are up when they arrive on duty at 8am and usually about four are still in bed if they want to lie in. This was discussed with the provider who said he will monitor to make sure people only are assisted to get up in the mornings when they are ready. Relatives spoken with said they could visit when they want to and are offered drinks. The meal was taken with some people in the dining room and consisted of cottage pie 2 vegetables, a choice of puddings was offered. All said they enjoyed the meal and the wastage seen was minimal. The menus provided did not include a choice at lunchtime however it was clarified with the cook and people spoken with at lunch time that they are able to choose another meal if they don’t want the one on the menu. The cook said a cooked meal is provided for the evening meal, which she prepares and is served by carers. She said the home has recently won the Gold Award for Nutritional value of meals. A visitor said their relative has fruit every day, loves their meals and the home had put on a special birthday party and the cook makes birthday cakes. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 18 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): 16,17,18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who live at the home and their relatives are confident that their complaints will be listened to and acted upon, their civil rights are respected and safeguarding issues reported appropriately. EVIDENCE: The provider said a copy of the complaints procedure is given on admission, signed and kept on service users’ files. These were seen on some records checked. The homes complaints procedure was seen displayed outside the manager’s office Survey comment forms received indicated that people are aware of how to make a complaint. A relative’s comment form showed they had “never made a complaint”. A comment form completed by a person who lives at the home stated, “daughter would complain if needed.” Election voting cards were seen, ready for people to use the postal vote, although the provider said some people go to the polling stations and his car is insured if needed. Two of staff spoken with said they have NVQ level two in care and this includes some safeguarding training, although they haven’t received extended safeguarding training as yet, and were was aware of their duties under the Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 19 Whistleblowing policy. Another carer spoken with had not had safeguarding training to date, when asked was aware of duties under Whistleblowing policy. The manager said safeguarding training had been arranged with the local authority. Before the visit the manager had reported concerns about a person’s finances, which has been investigated under the local authority’s safeguarding procedures. The manager discussed further concerns in respect of the handling of another person’s finances, which has since been referred for investigation to the local authority. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 20 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): 19,22,24,26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a clean, safe, and well-maintained environment for people to live in. EVIDENCE: A survey comment form stated the home is “ beautifully fresh and clean”, one person commented that they considered the home to be usually clean”. Information provided by the manager on the pre inspection questionnaire shows some refurbishment had occurred e.g. new kitchen equipment, new tumble dryer, bathroom redecorated and new bath hoist purchased. Information on the pre inspection questionnaire records that the home has an annual maintenance programme and the last fire officer’s visit was on 25.4.06 and no requirements or recommendations were made. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 21 A ramp provides people access to the home from the garden; the borders were stocked with plants. The laundry floor was worn and the paint was peeling at the time of the visit. However the manager has since confirmed that the scheduled repainting of the laundry occurred on the 23 April 2007. The laundry equipment was satisfactory, although there was discussion with the manager regarding some damp areas on outer wall where the electrics are fitted; subsequently the provider confirmed with the Commission that this has been checked by an electrician and is safe. People’s bedrooms seen had been personalised with family photos and pictures the rooms were clean and looked comfortable. There was discussion with the manager about a small area on a radiator cover being broken, which he will fix. The shaft lift was taken from 1st to ground floor, it was slow and smooth and a handrail was in place. Extensions to the emergency call points had been provided in bedrooms, although a person spoken with said they could not access the emergency call when sitting in the lounge. This was discussed with the manager who said plans are being made for a new system to be fitted in the near future, which would include pendants and alarm mats. A person who lives at the home spoken with she said staff more or less answer the emergency call straight away in the night. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff induction procedures, training opportunities and staffing levels are satisfactory, however people living in the home are not currently supported and protected by full staff clearance processes. EVIDENCE: The care staffing levels on the roster provided prior to the visit seen showed care staffing levels 3 carers 8am-4pm 1 carer 2pm-10pm 2 carers work 4pm-10pm 2 carers work at 10pm to 8am. People’s comment forms show “Staff always friendly and helpful” “most staff listen and act on what residents say and are available when needed”. “Can’t fault staff”. Relatives comment cards state “staff employed at this time are very good.” “Staff always have time to talk to residents”. Pre inspection questionnaire information shows that staff training has been provided including manual handling, first aid, food hygiene, medication and fire training NVQ 2 &3 Palliative care, dementia awareness and common induction standards in the 12 months since the last inspection and further training is Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 23 planned for infection control and medication training, and ongoing NVQ care training. This was confirmed with staff spoken with. Two of the three carers on duty spoken with considered that there is enough staff on duty to meet service users needs appropriately. One said they felt that more staff was needed on a Monday morning. Staff recruitment records seen showed that application forms had been completed, 2 references obtained, staff provided with a contract of employment and a job description. However the provider said the CRB (Criminal Records Bureau) office had told him that CRB clearance was portable and the decision to accept them was at the discretion of the manager. He was not aware of the Department of Health guidelines in respect of staff being able to start work under supervision prior to CRB clearance and he said he had never done any POVA first checks. The provider said staff who start work and don’t have any experience complete a 6 day induction course with the local authority, those who start work and have some previous experience do a shorter course and the home also provide some induction before staff start work. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 24 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): 31,32,33,35 38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The manager has the qualifications and experience required to manage the home, which is run in the best interests of the people who live at the home. EVIDENCE: The manager said he has obtained the NVQ level 4 management and Registered manager’s qualifications since the last inspection and a new office has been provided to support meetings being held and to enable some staff training to be delivered onsite. Records seen showed that staff meetings had been held. Two members of staff spoken with said “very well supported by management, very approachable” Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 25 another also said “ the management think a lot about the people who live here.” Questionnaires that form part of the homes quality assurance programme had been completed and showed the people who live at the home and their relatives are generally satisfied with the service. Some people’s financial records were checked and the cash and records balanced. However, the manager said he has concerns about one person’s finances, which has since been referred for investigation under the local authority’s safeguarding procedures. This did not involve staff at the home. The manager has provided the Commission with a record of system and service checks on the pre inspection questionnaire prior to the visit, which are considered to be adequate. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 26 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 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 3 18 3 3 X X 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 27 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. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 2. OP22 16(1) 3 OP29 19(1) The registered person shall 30/04/07 make arrangements for the recording, of all medicines whether they are regularly used or not. Provide further training for all staff that administer medications. This makes sure people are getting their medication as prescribed. The registered person must 30/04/07 ensure that staff presence is maintained in lounge areas to enable people to obtain staff easily. The registered person must 30/04/07 obtain recruitment checks, within the guidelines set by the Department of Health, from CRB and POVA or POVA first, prior to staff commencing work at the home, and a record of this retained to the next inspection. Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 28 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 3 Refer to Standard OP7 OP8 OP9 Good Practice Recommendations The care plans need to be further developed to inform staff of the action to take to ensure each persons full needs will be met Nutritional assessments should be documented to ensure the information in the care plan in respect of the people’s dietary requirements is evidenced. Information and advice should be obtained from the prescriber for medication that requires a member of staff to make a judgement on a person’s medical condition before administrating the medicine. This information should be recorded in the care plan. This makes sure that staff involved in administration are making the correct decision on how and when to administer and the person is receiving the correct treatment. The date an authority to alter MAR entry was made should be recorded. This makes sure that there is an accurate record of why the entry was changed. The temperature of the room where medication is stored should be regularly checked. This makes sure that medicines are being stored at the temperatures recommended by the manufacturer. Prescriptions should be checked before going to the pharmacy to make sure they have the correct medication and dose on. Staff should check with people that they are seeing their visitors in rooms of their choice; including in the privacy of their bedrooms. The registered person should confirm if advocacy arrangements are in place to ensure the safe handling of the people’s finances particularly for those unable to make informed choices. Two signatures should be obtained on the people’s records when deposits or withdrawals are made from monies held by the home on their behalf. 4 5 OP9 OP9 6 7. 9 OP9 OP13 OP35 Carleton Court DS0000006170.V328146.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. 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