Inspection on 13/07/06 for Carlton House

This inspection was carried out on 13th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 House 04/07/08

Carlton House 05/07/07

Carlton House 08/12/05

Carlton House 11/07/05

Carlton House 12/01/05

Carlton House 04/06/04

Carlton House 12/01/04

Carlton House 17/11/03

Carlton House 24/06/02

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

CARE HOMES FOR OLDER PEOPLE Carlton House 267 Hainton Avenue Grimsby North East Lincs DN32 OLA Lead Inspector Jane Lyons Unannounced Inspection 13th July 2006 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 Carlton House DS0000002911.V304720.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 House DS0000002911.V304720.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton House Address 267 Hainton Avenue Grimsby North East Lincs DN32 OLA 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) 01472 360878 Mrs Katrina Peerbux Position Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005. Brief Description of the Service: Carlton House is registered to take 10 service users with residential care needs; these beds are also registered for service users with needs associated with dementia. The home is a detached house situated in a busy residential area of the town; it is close to the town centre and on local bus routes. Accommodation is provided on two floors; there is chair lift access to the first floor. There are four single rooms and three shared rooms; one bedroom is provided on the ground floor. The home has one lounge, one dining room and an outside courtyard. The home has a pleasant, homely inclusive atmosphere. The home is owned by Mrs Katrina Peerbux. The acting manager is Mr A Peerbux. Weekly fees are: £329- £367. The home does not operate a system whereby the fees include a third party contribution. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing and chiropody. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available on request. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • • The visit to the home lasted from 9 a.m. until 4.30 p.m. All nine residents spent some time chatting to the inspector. Two staff, a visiting district nurse, the acting manager and the owner also talked to the inspector. Records about the care provided, and other records about the running of the home were looked at. Questionnaires about the home were sent to all the residents, staff, relatives and three healthcare professionals involved in supporting residents. All the residents and relatives questionnaires and four of the staff ones were returned at the time this report was written. The inspector observed how staff and service users worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. • • • • What the service does well: Residents spoken to said that they liked living at Carlton House and were well looked after. Relatives spoken with during the inspection were positive about the home and commented on the caring nature of the staff. A visiting District Nurse also commented on how well she thought the residents were cared for. Staff spoken to were enthusiastic and liked working at the home, they were keen to ensure that residents receive high standards of care. Residents liked the food provided, are well fed and encouraged to eat a healthy diet. There were good visiting arrangements and visitors were made to feel welcome, discussions with the son and grandson of one resident confirmed this. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 6 Proper recruitment checks were made before new staff start in the home to ensure they are safe to work there. Staff reported that access to training was good, this means residents’ care is delivered in a way that is up to date and based on current good practice. What has improved since the last inspection? What they could do better: Records relating to medication must improve to help ensure residents get the right medication they need at the right times. Service user care plans must improve; individual service user plans were available however some records did not have enough information about all the needs of service users. This means the home was not able to show that all aspects of health, personal and social care needs of service user’s are identified and planned for. The self- closing devices on the doors must be repaired to ensure that the safety and welfare of the staff are better protected. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 7 Carpets with malodours must be cleaned more regularly to ensure that the residents live in a home which is pleasant and comfortable. Regular reviews of aspects of the homes performance through a good programme of self review and consultations, which includes the views of service users, staff, relatives and others for example care managers must be carried out. This is needed to ensure continuous improvements are made. 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. Carlton House DS0000002911.V304720.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 House DS0000002911.V304720.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has improved the admission procedure ensuring all residents have their needs properly assessed before moving in which will better ensure that the home can provide all the support they need. EVIDENCE: Earlier in the year a new resident was admitted whose physical and psychological needs could not be met at the home and the resident was transferred to a home that was more appropriate for his needs. Since that time the homes’ admission procedures have improved; the home has admitted two more new residents who were fully assessed by the acting manager prior to admission and it is clear that their needs are more suited to the care support and facilities provided at the home. These residents told the inspector that they had not taken the opportunity to visit the home prior to admission but had relied on family members to assess its suitability, which had been a satisfactory arrangement. The acting manager confirmed that prospective new residents were given copies of the statement of purpose and service user guides; he commented that families were also Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 10 looking at the homes’ inspection reports on the internet prior to making their decisions. The format of the homes needs assessment covers all required areas; copies of completed assessments were detailed and appropriate. Copies of the Local Authority assessment and care plans are obtained prior to admission for those residents referred through the local Social Services care management teams. In addition to the pre admission assessment the home undertakes a further assessment of strengths and needs once the resident has arrived. It is on the basis of both these assessments that the residents plan of care is formalised. The written contract/statement of terms and conditions documents were agreed with residents and held on file. Residents spoken to were happy that their care needs were being met. Staff spoken to were aware of residents’ personal care needs. Visiting relatives were also happy with the care being provided. There was good evidence to demonstrate that care staff were accessing a broad range of service specific training which will help ensure that they have the skills to enable them to deliver up to date care methods and have a better understanding of the varied conditions common to the elderly. The home does not provide intermediate care support. Carlton House DS0000002911.V304720.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health and personal care needs are generally met, however the quality of the ongoing maintenance and up dating of the care plans is inconsistent. Medication procedures need to improve to enable staff to make sure service users get the medication they need. EVIDENCE: Residents said that staff treat them well and they were happy with their care. This was also the view of relatives that were visiting. The care programme format remains unchanged; it is comprehensive and user- friendly. The way in which the care plan recorded likes, dislikes and preferred routines demonstrated the residents had been consulted, however they had not signed the plans; advice was given to devise a form which asks the resident where appropriate, or their relatives to acknowledge that they are aware and agree with the contents of the care plan. The inspector case tracked three care programmes which included the two new admissions. Detailed assessments were in place and individual plans of care developed to support the majority of needs; gaps were identified with one resident needing a plan to support his needs associated with diabetes; another Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 12 file did not contain a moving/ handling risk assessment when complex needs had been identified on assessment and plans had not been developed to support changes in care provision e.g. one resident sustained an arm injury following a fall and required support with dressings. Care plans did detail clearly the support required from staff to meet resident’s needs associated with their dementia. The staff told the inspector that they had been more involved with writing the care plans which they were enjoying. The programmes were generally well evaluated and the quality of the recording had improved with more detailed review notes in place. There was good evidence in the programmes that regular formal reviews had been held; there was also good evidence that the home sought support from the health care professionals such as Community Psychiatric Nurses and District nurses when necessary. One of the District Nurses visited the home during the inspection and confirmed that the communication was good, staff were always very helpful and she had observed that they demonstrated a very caring and supportive attitude towards the residents. A survey was received from relatives which detailed concerns that they felt they were not always informed about their loved one’s health care outcomes such as contact with the G.P. etc; this issue was passed on to the management who confirmed that they would improve communications in this area. Relatives visiting a service user during the inspection confirmed that they were always informed of any changing needs and visits to the G.P. etc. Some aspects of the medication system had improved; the home now had records in place to support the regular monitoring of the room temperature which were satisfactory and documentation was now in place from the G.P. to sanction the practice of covert administration for two service users who experienced difficulty in taking their tablets. Examination of the medication administration records still revealed a small number of gaps where the staff had not signed or used a code to account for the omission. There were no residents self- medicating. Storage of medications was satisfactory. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for providing activities, visiting, meals and supporting residents to make choices met with the expectations of the residents. EVIDENCE: Residents and visitors were happy with the visiting arrangements and it was clear that residents are supported to keep in touch with friends and family. One resident recently celebrated her 101st birthday with parties held with her family and in the home. Residents also said that they felt able to make their own choices about how they spend their time. They can rise and retire to bed at times to suit themselves, choose where to have their meals and what clothes they wanted to wear. They also commented that they could spend time in their rooms if they wanted to but usually preferred to sit during the day in the lounge or the dining room. One resident told the inspector how much he enjoyed reading the daily newspaper and that sometimes he went down to the shop to collect it. There was evidence from observation and interview that residents have the opportunity to speak to staff and management on a one –to –one basis; advice Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 14 was given to arrange residents meetings which would provide an opportunity for residents to discuss issues collectively. The activity and entertainment programme continues with service users preferring to access more one-to one time with individual staff members looking through family photographs and talking about their lives. Evidence from surveys and discussions identified that staff were working hard to encourage and motivate the residents to participate in many of the activities but a number remained very reluctant. Consideration to further vary the programme and to include more regular trips out may interest these residents. The staff who are responsible for cooking and serving the meals know residents likes and dislikes very well. Residents spoke positively about the quality of the meals, comments were: “The food is always nice” and “I love the meals”. The menu board in the hall displays the week’s menu choices; staff confirmed that the menus were due for review. Resident’s weights are monitored regularly and any concerns are referred to community health services for support. One of the residents likes a vegetarian diet and told the inspector that he rally liked the omelettes that the staff cooked. Assistance is offered to residents with individual needs. The mealtime was seen to be a very relaxed and social occasion with the staff interacting well with the residents. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Although significant improvements had been made to the recording of complaints received by the home and service users knew who they would make a complaint to efforts should be made to better inform relatives of the process. Recruitment and selection practices now better protect service users from abuse. EVIDENCE: The management of complaints had improved; since the last inspection the home had received a complaint regarding care practices. There were detailed records in place to support the investigation of the issues, outcome and action taken by the acting manager to feedback to the relatives and inform the staff. The complaint procedure was displayed in the hall; this needs to detail the current contact details of the CSCI. Four of the relatives surveys identified that they did not know how to make a complaint therefore the management need to address this. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint in place. There was evidence that the staff had accessed training in adult abuse and management of challenging behaviour. When asked about abuse, what it Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 16 was and what they would do if they saw a service user being abused, the staff answered correctly. The inspector found that recruitment practices were satisfactory; examination of staff files demonstrated that CRB checks/ POVA First checks had been obtained for new staff prior to employment. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Carlton House provides comfortable homely surroundings but efforts must be made to improve the odour control and décor in a number of areas to promote residents’ comfort and dignity. EVIDENCE: The home was comfortable; and generally decorated and furbished to a good standard. Resident’s rooms were personalised to the extent chosen by the individuals. The communal areas were all well utilised during the visit; service users commented on how happy and settled they were at the home. It was good to see a number of the residents spending time outside in the garden, they told the inspector that they enjoyed sitting outside in the sun and they liked the new water feature. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 18 The owner carried out a full audit of the environment in April; repairs, redecoration and refurbishment work was identified, although not all this work has been carried out. New garden furniture had been provided, a sink in one of the resident’s room replaced, repairs carried out to the kitchen units and recent decoration to some of the exterior paintwork has taken place. Further work to the exterior paintwork is required, the ground floor bathroom requires redecoration and the lavatory seat requires replacement. Issues around odour control were identified at this visit; two of the bedroom carpets had odours of stale urine and the dining room carpet had a stale odour. Staff carry out weekly checks of the hot water temperatures at all outlets accessible to service users; records and random checks during the visit evidenced that the hot water systems are managed effectively and safely. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 19 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 and 30 The quality outcomes in this area are good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides sufficient numbers of staff on each shift to meet the care needs of service users; staff are trained and competent to carry out their work. Recruitment practices afford sufficient protection for service users. EVIDENCE: The staffing levels in place were in line with the previous registration authority; care staff at the home also undertook housekeeping and catering duties. There were nine residents residing at the home; the management were currently recruiting two more care staff to ensure that three care staff were employed on all morning shifts. Two staff were rostered for the evening duty and one waking/ one sleeping member of staff during the night. The overall dependency in the home remained stable. Staff confirmed through discussions and surveys that they were satisfied with the staffing levels; residents told the inspector that staff always had time to help them with their personal care and to spend time with them during the day. New staff had been appointed since the last inspection. Inspection of their recruitment records showed that all the required checks were made before they started work. This is to make sure they were suitable for the job and not put residents at risk from harm. All the other recruitment documentation to comply with Schedule 2 was seen to be in place. Training records for three members of staff were examined; new staff had accessed induction courses and received training on moving/ handling. The Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 20 training programme identified that staff were on course to meet the mandatory course targets and had also accessed a variety of general and service specific courses; which have included dementia, activities, stroke awareness and management of aggression. The home currently has 33 of the staff trained to level 2 NVQ; two staff commenced the course in February and two more staff are due to start the course in August which demonstrates that the management are working towards the target of having 50 of the staff trained at this level. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36 and 38 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Although the acting manager has made improvements towards the management of the administration systems efforts must now be made to fully action all the outstanding requirements and implement a quality assurance programme to demonstrate effective management of the home; however service users were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities. EVIDENCE: The acting manager has now been in post for six months and improvements can be seen to the stability of the home, staff moral and aspects of the general management. Staff told the inspector that Mr Peerbux was very supportive, approachable and involved in all aspects of care for the residents. One staff Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 22 member also said that the rotas were much fairer, if issues were raised he took action, she went on to say that he was very patient and understood the residents needs very well. It is clear that Mr Peerbux has regular support form the registered provider, who spends at least one day per week at the home. Although a number of Regulation 26 visit reports have been received since the previous inspection, they need to be sent more regularly. Records to support the management of complaints and the supervision programme have improved significantly. There were accurate and up to date records relating to any personal allowances the home keeps on behalf of residents. The home has a good range of policies and procedures to support equality and diversity in the home, these include: dietary and religious needs, sexuality/ relationships, hearing / sight needs, dementia and challenging behaviour needs. A number of the general policies/ procedures now require review to ensure they reflect current practices in the home. No progress had been made to implement a formal quality assurance system; whilst the owner is sourcing a comprehensive and user friendly audit tool efforts must be made to gain service users, relatives and stakeholders views about the service. The home was physically safe and generally well maintained; maintenance certificates were up to date and available for inspection. The home has a detailed Health and Safety policy. Safe working practices are maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid at work, basic first aid, infection control and fire safety. Records showed that regular testing of the fire equipment was taking place; these records detailed that the self closing devices for the laundry room and dining room doors had been out of order since December which must be addressed. Improvements had been made to the recording of food, fridge and freezer temperatures in the kitchen area. Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 23 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 3 X 2 Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement The registered person must ensure that all care programmes detail all service users needs and associated care interventions, Where necessary care plans must be revised and updated. Timescale of 21/12/05 not met. NEW TIMESCALE. The registered person must ensure that all risk assessment documentation regarding moving/ handling is in place to reflect the service users current risks. The registered person must ensure that staff complete the medication administration charts in accordance with Royal Pharmaceutical guidance. Timescale of 08/12/05 not met. NEW TIMESCALE. The registered person must establish and maintain an effective quality assurance programme. Timescale 31/03/06 not met. DS0000002911.V304720.R01.S.doc Timescale for action 31/07/06 2. OP8 13(4) 31/07/06 4. OP9 13(2) 31/07/06 5. OP33 24 30/09/06 Carlton House Version 5.2 Page 25 NEW TIMESCALE. 6. OP26 16(2)k The registered person must ensure that carpets with offensive odours are cleaned more regularly or replaced. The registered person must ensure that all self-closing devices fitted to doors are in full working order. The registered person must ensure that decorative improvements to the ground floor bathroom are carried out and that the lavatory seat is replaced. 15/08/06 7. OP38 23(4) 31/07/06 8. OP19 23 31/08/06 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. Refer to Standard OP28 OP16 Good Practice Recommendations The registered person should ensure that the 50 of the care staff have achieved NVQ level 2. The registered person should ensure that the complaints procedure is updated to reflect the current contact details of the CSCI and a copy of the complaints procedure is provided to all relatives of current residents at the home. The registered person should ensure that all reports to support formal monthly visits to the home are sent in to the Commission on a regular basis. The registered person should review a number of the policies/ procedures to ensure they reflect the current practices at the home. 3. 4. OP37 OP33 Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carlton House DS0000002911.V304720.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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