Inspection on 30/10/07 for Carlton Hall Residential Home

This inspection was carried out on 30th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Carlton Hall Residential Home 15/09/08

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

CARE HOMES FOR OLDER PEOPLE Carlton Hall (Lowestoft) Limited Chapel Lane Carlton Colville Lowestoft Suffolk NR33 8AT Lead Inspector Claire Hutton Key Unannounced Inspection 30th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carlton Hall (Lowestoft) Limited DS0000069801.V346314.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. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Hall (Lowestoft) Limited Address Chapel Lane Carlton Colville Lowestoft Suffolk NR33 8AT 01502 513208 01502 567643 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) Carlton Hall (Lowestoft) Limited Mrs Shirley Baxter Care Home 42 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (31) of places Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels within the home must be reviewed together with the regulatory authority 6 months from the date of the certificate of registration. This service is newly registered please see below. Date of last inspection Brief Description of the Service: Carlton Hall is a registered care home for older people, providing residential care for up to forty-two residents (Up to 11 of whom may have dementia). The Registered Owners of the home changed this year from Mr and Mrs Baxter to Carlton Hall (Lowestoft) Ltd. Mrs Baxter has remained the Registered Manager. Carlton Hall is a large detached country house, situated in its own grounds. The home opened several years ago, as a small home. Over the years the property has been extended, and the numbers of registered care beds have increased. The latest extension was added during 2006, increasing the number of beds from thirty-five to forty-two. The home is situated in the village of Carlton Colville, on the outskirts of Lowestoft, north Suffolk. The accommodation for service users is situated over two floors, with the majority of service user accommodation located at ground floor level in the extensions that have been added to the house over the years. The home is set in attractive grounds which include a long driveway, visitors and staff car parking areas, mature gardens and grassed areas, patios and decking, a fenced off ornamental pond, and paddocks used for animal grazing during different periods of the year. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.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 key inspection that focused upon the core standards relating to Older People. It took place over two days lasting twelve hours. The inspection process included visiting communal areas of the home, discussions with six staff members, three relatives and four residents at the home. Observations of staff and resident interaction were made on both days. There was examination of a number of documents including residents care plans and associated documents, medication records, the staff rota, menus and records relating to health and safety and records relating to recruitment and training of staff. The report has been written using accumulated evidence gathered before and during the inspection. The Commission had received an Annual Quality Assurance Assessment (AQAA) completed by the manager before the inspection. A number of surveys were sent to the home to seek the views of relatives, staff and residents. Two surveys were received back from residents and two surveys were received back from relatives. No surveys were received back from staff. A placing Social Worker was also spoken with on the telephone. This service is newly registered because the Registered Owners of the home changed this year from Mr and Mrs Baxter to Carlton Hall (Lowestoft) Ltd. Mrs Baxter has remained the Registered Manager. What the service does well: What has improved since the last inspection? At the last random unannounced inspection conducted at this service on 15th December 2006 a repeat requirement was made in relation to ensuring staff receive supervision. At this inspection evidence was found that staff are offered and receive supervision. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 6 The visit to the establishment in December 2006 focused upon the registering of a new extension to the home to accommodate 11 people with dementia. What they could do better: At the inspection in December 2006 a repeat requirement was made in relation to the development of a quality assurance system in order that the views of those people using the service can be listened too. This was once again discussed with the manager of the home and was agreed to be developed. There is also an outstanding requirement relating to the need to have systems in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. This was discussed with the owners and they agreed they had not actioned this and therefore resident and staff are still at potential risk from the spread of infection. In the main part of the home that accommodates older people who need personal care and support the home does very well, however in the dementia care unit (yellow unit) not everyone had a care plan in place. Therefore currently the home cannot ensure consistent care delivery. There was some concern expressed that one resident who had been at the home on respite had lost weight during their stay, but inadequate records had been kept to either disprove or substantiate this. Therefore, to ensure health and weight is maintained nutritional screening must be undertaken on admission and subsequently on a periodic basis. Weight gain or loss, should be noted and appropriate action taken to ensure the health and well being of all residents at the home. The home is currently unable to demonstrate that it is taking concerns and complaints seriously, therefore a record of all complaints must be maintained with the action taken with regard each complaint made. The home must be safe and suitable for its stated purpose therefore first floor windows must be assessed for the risk they present to residents and action taken to prevent falling from windows. Finally residents must be protected therefore records of accidents must be maintained, up to date and accurate. Please contact the provider for advice of actions taken in response to this Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 7 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. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.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 Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect that they have their primary care needs assessed prior to moving into the home, however those with more complex needs around dementia cannot be given assurances that their needs will be met. EVIDENCE: The service has recently revised and sent the Statement of Purpose and Service Users Guide to The Commission in order that they may become registered as Carlton Hall (Lowestoft) Ltd and these documents are also available at the home upon request. Five different residents records were examined to ascertain if an assessment was conducted before a resident moved into the home. The minimum requirement of obtaining a summary of a care assessment, through care management arrangements, before a resident moves into the home had been obtained. In some cases the manager had visited prospective residents either Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 10 in hospital or at home and had conducted her own assessment. One resident also had discharge information from hospital that helped towards planning their care. However for those resident that are using the dementia care unit there was limited information on their dementia and how that had manifested and impacted upon their daily lives or potentially other people. This was particularly true for those residents who used the service for respite care. The social worker spoken with said that they were generally satisfied with the main home and that families are happy using this, however there has been concerns raised by relatives who use the respite dementia care beds and these concerns have been raised with the home. One relative who used the dementia respite service at the home commented ‘My husband came out worse than he went in. He had a bad experience both physically and mentally’. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents in the main part of the home can expect that their health, personal and social care needs are set out in an individual plan of care and therefore find they are looked after well. However not all residents in the dementia unit have a plan in place to ensure consistent care delivery. All residents are protected by the homes medication procedures, they are treated with respect and their right to privacy is upheld. EVIDENCE: The system of choice for care planning at Carlton Hall is ‘Standex’. This appears to be working well for those residents within the main body of the home. Care plans were in place based upon the assessments made and had evidence of review. Four residents spoken with and one visitor in the main part of the home were very satisfied with the care and support they received. The visitor had been coming to the home for some years and felt that the person they visited was very well cared for and was very complementary about the home and staff. In speaking to one resident about her care it was evident that the plan did match what the resident was saying and expected from the Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 12 home. All residents spoken with confirmed that they were treated with respect at the home and that their privacy was respected. For three people out of the five residents tracked there was not a comprehensive care plan in place. These three people were or had been resident in the dementia care unit, known in the home as the yellow section. For one of these residents there was continual daily recording, but no plan. Staff spoken with had got to know the resident well and were able to describe that the resident displayed behaviour that showed they were frustrated and agitated – mainly whilst receiving personal care. This displayed itself as not being cooperative with staff and grabbing at staff or pushing them away. Staff said the resident could be very strong when doing this. Another concern of staff was that the resident regularly refused medication that was required to control epilepsy. Both of these areas of care should have been identified and recorded with a strategy of care and support for staff to follow. This could then be reviewed to show any change or deterioration in the resident. As there was no plan there was no evidence of review. From observation and talking to staff another resident had dementia care needs that were not adequately recorded in a plan. These related to communication by a resident. They presented as very repetitive in their speech and on occasion used foul language. In addition the person needed a plan in place around safe touching. E.g. were staff able to cuddle the resident when the resident cuddled them – what was safe and permissible for the safety of all. Neither of these elements of care were found to be in a care plan. Care records showed that there was access to a variety of health professionals including GP, District Nurses, opticians and chiropodists. Several residents had received the flu vaccination. District nurses also enabled the home to access equipment such as specialist cushions and mattresses for pressure care for those residents assessed as needing them. Staff were seem to be using manual handling equipment such as hoists and handling belts for residents who needed it. A staff member spoke of referrals to the falls prevention officer in relation to one resident and was aware of how to refer others should the need arise. The Social Worker spoken with believed one of their clients had lost a significant amount of weight whilst at the home for respite. In looking at records there was insufficient evidence available to support or substantiate this. Records for other residents at the home did not have a record of regular weight monitoring. One relative wrote in their survey ‘My husband had 3 falls during his stay and they were all bad falls. There are grey areas, which I have found difficult to determine i.e. different stories regarding the first fall when he was badly hurt’. The records for these incidents were examined. The daily recording by staff was clear – there indeed had been 3 incidences. The accident records were requested and no accident record could be found for 2 of the 3 occasions. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 13 There was a lack of coding of accident records and therefore information was unable to be traced satisfactorily. This particular resident did not have a care plan in place that included a risk assessment with particular attention to falls prevention. Medication in the yellow section was examined. This was kept secure. Staff spoken with were confident in their knowledge of drug administration and confirmed they had received training. (A certificate on file also confirmed this) The system currently in use at the home is the Boots monitored dosage system. Medication for one resident was audited and found to be correct. The medication administration records were correctly completed with the correct codes being used. One resident who required their medication to control seizures but frequently refused it had their medication covertly given to them upon the instructions of a GP. The home had a record of these instructions, but they were not with the medication administration record, but in the daily notes. Throughout the inspection staff were observed to knock on bedroom doors before entering, interaction between staff and residents was observed to be positive, friendly and respectful. Resident’s letters were placed in named slots where they could collect their unopened mail. In the laundry residents clothing was labelled with their name to ensure that clothing was returned to the correct person following laundering. The laundry areas had named boxes where resident’s smaller items of clothing were placed for their return. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good quality food available and are presented with opportunities to lead a lifestyle of their choosing. EVIDENCE: One resident was spoken to whilst they were washing and drying cups from the afternoon cup of tea. They explained that they liked to be useful and also set the dining tables and helped out where they could. The dining areas around the home were all nicely set out and provided a pleasant dining experience. On the same afternoon one of the activities staff was going around the living room asking residents what they would like to do that afternoon. A consensus was reached to first play cards then roulette; she then went to see if some other residents not in the room wished to join in. That morning the activities organiser in the dementia care unit (the yellow section) had been making buns and decorations for Halloween. The yellow section had several decorations relating to Halloween upon display. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 15 Residents and staff spoke of freedom to get up and have breakfast any time they liked and the kitchenette areas of the home made this very practical. Visitors and relatives were seen at the home and spoken with. One relative said how they could visit any time and that they liked to take their relative out into the grounds and see the horses that grazed near by. One resident said that their son visited every day and brought toiletries like toothpaste when needed. Two relatives spoken with said that they had come to appreciate the home more as time had gone one. Initially they had concerns, but these had now been resolved and they had come to understand how well their relative was cared for. The home has a good long standing reputation for good home cooked catering. On the first day kitchen staff were seen in the afternoon to be making a selection of homemade cakes. The cook was spoken with and she said that she tended to make smaller buns rather than large cakes to cut up because the residents preferred this. The cook explained that there was a menu that was on a four-week rotation. Each day residents were asked their choice for their main meal that day. If they did not like or wanted something different then the cook was able to offer a homemade alternative, as she tended to make extra some days and then freeze this as a choice for residents. She explained recently the change in menu upon the request of residents to have different varieties of fish. Meals are served from hot trolleys to ensure the food stays hot and safe whilst being transported to the different units. The two surveys received back from residents responded positively to the question ‘do you like the meals at the home’. Two residents spoken with during the visit to the home said they liked the meals and the potions were what they wanted. There were frequent refreshments served from a trolley. Around the home were bowls of fruit and sweets for the residents to help themselves when they chose. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse. The home currently does not consistently demonstrate that it listens to concerns; therefore the procedure may not be as effective as it could be in improving the service on offer. EVIDENCE: The home has a complaints procedure in place and this can be found in the Service Users Guide. The procedure is also displayed upon the notice board as you enter the home. The service states that they have not received any complaints and do not have a log of complaints. The social worker for one person who used the service was under the impression that a complaint had been shared with the service and that the home had apologised. This complaint related to laundry and care of a resident. A relative at the home was concerned about a missing watch and had shared the concerns with staff at the home. However the home did not treat this as a complaint and therefore had not recorded any action that they had taken, though they believed they had taken the concern seriously. The two surveys received back from residents both said that staff listen and act on what they say and that they know how to make a complaint. In the survey to relatives we asked ‘Has the care service responded appropriately if you or the person using the service has raised concerns about the care’. One relative said ‘always’ the other response said ‘sometimes’. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 17 Staff record showed that staff had received training in safeguarding. One staff member spoken to was aware of protection of vulnerable adults (POVA) and confirmed they had attended training. Staff records also showed that when recruited a CRB (Criminal records bureau) check was made including a POVA check. The finances of one resident were discussed and money held for that individual was checked and found to be correct. Money is held in a safe that is secure and appropriate records are kept. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Carlton Hall provides a good quality environment that is well maintained, however currently residents are being put at risk of infection due to a lack of suitable laundering of linen and at potential risk of falling from unrestricted windows. EVIDENCE: In December 2006 the new wing to accommodate 10 people with dementia was registered. We visited the premises and recorded the following about this new extension. ‘There are 10 new bedrooms added in the ‘Yellow wing’. These all conform to the environmental standards of size with additional en-suite. Each room has the required furniture, fittings, carpet and curtains. All this is new and of good quality and light and airy. The en-suites have a toilet and wash hand basin. Temperature was said to be restricted on all Wash hand basins. Room 33 was tested and found to be at Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 19 42°c. The door to the en-suite has a hinge and therefore can be opened to a double door to allow wheelchairs to use the room. There is sufficient storage in the form of cupboards and a large walk in cupboard. The main living area is a lounge dinner with a kitchenette in one corner. This will serve drinks, tea and breakfast. The main meal of the day will be transported from the main kitchen in a hot trolley. The lounge has sufficient chairs to accommodate visitors. Each bedroom had 2 chairs. There are 2 assisted bathrooms with toilets. There is a toilet near the communal area. The temperature of one assisted bath was taken and found to be 42°c. There is a small courtyard that is created by the circular design of the unit. This small courtyard had been newly planted.’ Upon this visit to the home the yellow unit was in use and had been well maintained and was clean throughout. A change that has been made since the new unit has come in to operation is the use of walkie talkies. The use of these was discussed with the manager. The voices that can be heard coming from the device carried by staff may be confusing and worrying to a person with dementia. The manger agreed to review their usage in the yellow unit and spoke of their intention to review the telephone situation within the home as a telephone extension on occasions is needed in the yellow unit. The remainder of the home was well maintained and attractively decorated in keeping with the homes style. Furnishings in the home were well maintained and comfortable. Residents spoken with confirmed that the home was well maintained and comfortable. The grounds were attractive and residents were observed enjoying the view of the grounds. The whole home was clean and there were no offensive odours in the home. Cleaning schedules were seen to be completed. The handyman was spoken with and he said how staff noted any repairs for him to maintain in a book. He was knowledgeable about health and safety matters including maintaining hot water temperatures around the home. The first floor bedrooms were visited and found not to have any restrictions on the windows to prevent a person from falling from a height. At the visit to the home in December 2006 we said in the report ‘The laundry currently has 2 domestic machines with a third on order. The owners agreed to replace the third machine with an industrial one that will sluice wash and deal Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 20 with foul linen.’ At this inspection the home were found to be dealing with foul laundry without having purchased an industrial washing machine. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are supported by sufficient trained and competent staff and are protected by the homes recruitment procedures. EVIDENCE: The home operate a roster that rotates every two weeks. Staff have the same pattern of working and any changes are then actioned by the manager or her assistant. During the visit a staff member had gone off sick and the shift was covered. The roster showed all staff working at the home. There are 5 care staff on duty with two staff in the yellow unit. In addition there are staff who come in as breakfast staff and tea staff (08.30 to 13.30 and 16.30 to 20.00) there are also 3 activities staff, A cook and assistant cook, 4 cleaners each day, 1 laundry person and the handy man. At night there is 4 care staff one of which is a senior. During the week there is also the manager and the assistant manager on duty 09.00 to 17.00. A relative had contacted us about a lack of staff on a specified day. Records were examined as the staff employed upon that day and were found to be in excess of the staffing levels listed above. Recruitment and training records for three staff of different designations were examined. The recruitment records included two references and an enhanced Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 22 CRB check completed for all staff recruited. The application forms did not comply to the revised regulations and need to be reviewed by the home. There was evidence of induction and supervision of staff. The home have invested in dementia care training for most of the staff at the home. Most staff even if they do not work in the yellow unit have the National Certificate in Further Education in Dementia awareness from Otley College. Manual handling certificates and medication and safeguarding were all up to date. The manager said she had new dates planned for first aid and 8 staff were booked on basic food hygiene refresher course. Two staff spoken with had obtained their NVQ in care. One member of staff said she was very happy at the home and staff receive good training. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect that the home is managed by a person who is fit to be in charge and that their financial interests are safeguarded. They cannot be assured that there are quality assurance processes, which inform the development of the service. Residents cannot be assured that their health, safety and welfare is always protected. EVIDENCE: The homes registered manager reported that they had achieved their NVQ level 4 combined care and management award. The assistant manager was also currently enrolled on this course and hoped to achieve her NVQ 4 combined award by June 2008. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 24 Quality assurance was discussed with the manager and no progress had been made on the requirement made at the last inspection. The home does hold some personal monies for residents. These were found to be kept secure with appropriate records kept. In relation to record keeping the AQQA completed by the home confirmed that all policies and procedures within the home had recently been reviewed. Reference has been made to records relating to individual residents not been adequately kept in relation to care plans and accident records. The AQQA confirms that all equipment and utilities have been regularly serviced. The handyman spoken with also confirmed this was the case and was knowledgeable about health and safety matters. Staff training in health and safety matters was appropriate. However mention has been made in the environment section with regard to inadequate laundry of linen and the risk of falling from unrestricted first floor windows. Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 3 3 X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X 2 2 Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP33 Regulation 24(1)(a)( b)(3) Requirement The registered person must establish and maintain systems for reviewing the quality of care which includes consultation with service users and their representatives. (This is a repeat requirement) Systems must be in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. This includes appropriate laundering of soiled and foul linen. (This is a repeat requirement) A person centred plan of care must be set out for every resident at the home to ensure all aspects of health (including their mental health i.e. dementia and falls prevention), personal and social care needs are met. Nutritional screening must be undertaken on admission and subsequently on a periodic basis, including weight gain or loss, and appropriate action taken to ensure the health and well being DS0000069801.V346314.R01.S.doc Timescale for action 01/01/08 2. OP26 13 (3) 01/01/08 3. OP7 15 01/01/08 4. OP8 12 01/01/08 Carlton Hall (Lowestoft) Limited Version 5.2 Page 27 5. OP16 17(2) schedule 4 6. OP19 13 (4) 23 (2) 7. OP37 17(2) schedule 4 of all residents at the home. The home must demonstrate that it is taking concerns and complaints seriously, therefore a record of all complaints must be maintained with the action taken with regard each complaint made. The home must be safe and suitable for its stated purpose therefore first floor windows must be assessed for the risk they present to residents and action taken to prevent falling from windows. Residents must be protected therefore records of accidents must be maintained, up to date and accurate. 01/01/08 01/01/08 01/01/08 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 OP3 Good Practice Recommendations Assessment by the home should include information on how an individual dementia has manifested and how that may impact upon ones live or indeed those around them. This will ensure the home are then able to respond appropriately to supporting that individual. The instructions from the GP to give medication covertly should be held with the medication administration record for staff to refer to at all times as this practice deviates from the homes normal medication administration practice and policy. The use of the walkie-talkies may cause distress to some people with dementia. The methods of communication to staff should be reviewed. 2. OP9 3. OP22 Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carlton Hall (Lowestoft) Limited DS0000069801.V346314.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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