Inspection on 27/02/07 for Carlton House Dispersed Scheme

This inspection was carried out on 27th February 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carlton House Dispersed Scheme 13/01/09

Carlton House Dispersed Scheme 30/01/08

Carlton House Dispersed Scheme 05/09/06

Carlton House Dispersed Scheme 04/10/05

Carlton House Dispersed Scheme 12/04/05

Carlton House Dispersed Scheme 04/08/04

Carlton House Dispersed Scheme 25/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Carlton House Dispersed Scheme 24 Wakefield Road Rothwell Haigh Leeds West Yorkshire LS26 0SF Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 27th February 2007 09:30 Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 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 Dispersed Scheme DS0000001432.V323694.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 Adults 18-65. 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 Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton House Dispersed Scheme Address 24 Wakefield Road Rothwell Haigh Leeds West Yorkshire LS26 0SF 0113 2827110 0113 2887523 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) www.craegmoor.co.uk J C Care Ltd Mr Robin Staincliffe Care Home 21 Category(ies) of Learning disability (21) registration, with number of places Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Carlton House 10 clients Carlton Cottage 5 clients Woodhouse Cottage 6 clients Date of last inspection 5th September 2006 Brief Description of the Service: Carlton House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The home is managed by Robin Staincliffe. The service is registered to provide care and accommodation for up to twenty-one clients with a learning disability and is spread over three properties. Carlton House has facilities for ten clients, Carlton Cottage is within close proximity in the same grounds, provides additional accommodation for five clients and Woodhouse Cottage is registered for six adults. The one double bedroom, at Carlton House, is used as a single room. Therefore the maximum number of clients admitted is nine. Woodhouse Cottage is located three miles away. It is a satellite facility, which is staffed separately, with Robin Staincliffe retaining responsibility as registered manager. The annexe is purpose built, Carlton House and Woodhouse Cottage were previously family homes, which have been adapted. Carlton House and Carlton Cottage are situated in large grounds, a perimeter wall encloses these and the main gates are secured. Woodhouse Cottage accommodates clients who are more independent. Access is not restricted. The cottage has gardens to the front and rear. The homes are well served by public transport. Both sites provide car parking for visitors. It was agreed with the management of the home to use the term client in the inspection report when referring to the people that live at the home. The minimum fee is currently £1186.71 rising to £1519.96 depending on the needs of the client. This fee includes transport, toiletries and chiropody treatment. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in September 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Surveys were sent to clients before the site visit. Responses are used as part of the evidence base for this report. The inspector spent 15 ½ hours on the site visit over two days. Feedback was given to the registered manager and two assistant managers. During the visits the inspector looked around the home, observed staff and client relationships, spoke to clients, staff and the registered manager. Care plans, risk assessments, healthcare records, financial records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: The home provides a service to people with very diverse and complex needs some of who are very difficult to accommodate. Clients spoken to at the inspection and client surveys were complimentary about staff and management. Comments included ‘staff are good, they help us do jobs, staff are friendly, staff are helpful, I like having staff around the clock, staff try to help me sort out my problems and after I feel better and more relaxed, staff treat me well and with respect, all staff at Carlton House are very nice, they listen to what you are saying if you are upset’. Client surveys stated that staff treat you well and staff listen. Staff and management had good knowledge of clients and were able to talk about their likes, dislikes, relatives, abilities and levels of support. Staff were very positive and thought the team worked well together. The management team provide good leadership and direction. Clients and staff are happy to talk to the management team if they are unhappy or have any concerns. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 6 Recording systems are good. Staff make sure they write clear accounts with enough information. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients’ needs are properly assessed before they move into the home. The registration is not appropriate because the units do not operate as one home. EVIDENCE: No clients have been admitted since the last inspection. Admission records for the last admission were looked at. A pre admission assessment identified the type of support they required and there were details of discussions with other professionals. The registered manager was preparing for a new admission and the pre admission information was looked at. The registered manager had visited the client and obtained information from other professionals. The assessment covered all key areas of need and potential risks had been identified. An application for a variation had been sent to the Commission because the prospective client was not covered by the current category of registration. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 9 The registered manager or assistant managers are responsible for coordinating admissions and completing pre-admission assessments. At the point of admission, each client should be issued with a contract that sets out the terms and conditions, the fees, and the room allocated. Three files were looked at of which only two had contracts. The section on the fees charged was left blank. The Care Homes Regulations state clients must be provided with details of the total fee payable in respect of the service they receive. Allocated rooms were not included. This ensures each client has an allocated room and if they have to move for any reason a new contract would be issued. One client was heard asking the manager if they could move rooms. The manager explained to the client, this could be looked at but other people would need to be involved and it was agreed a meeting could be arranged. The manager provided a spreadsheet that stated the current weekly charges range from £1186.71 to £1519.96. The registration is for Carlton House dispersed scheme, which covers three units. Carlton House, Carlton Cottage and Woodhouse Cottage. Carlton House has facilities for ten clients, Carlton Cottage provides additional accommodation for five clients and is within close proximity and in the same grounds, and Woodhouse Cottage is three miles away and is registered for six adults. The registered manager is responsible for all three units, although he spends very little time at Woodhouse Cottage. There is frequent telephone contact. Woodhouse Cottage operates as an individual unit and has separate staffing. An assistant manager is employed three days week and is responsible for the day to day running of the unit. The inspection process confirmed that these are very different and separate services. It is not appropriate that the units are registered as one service. The Commission is liaising with the registered provider and manager about the registration. Carlton House and Carlton Cottage are separate buildings and at each shift, one or two staff are allocated to work in the Cottage. These two units share laundry facilities but are generally run as individual units. However, some days meals for the Cottage are cooked in the main house, by staff and clients, and sometimes clients use the other units bathing facilities. There was no clear reason why some days the two units operate differently but there was evidence of inconsistencies, which can be confusing for staff and service users. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 10 The manager and assistant managers agreed to look at the registration of Woodhouse Cottage and the operation and interaction of Carlton House and Carlton Cottage. This process should include reviewing aims and objectives of each home and producing appropriate statements of purpose and service user guides. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care needs that relate to behaviour and risk have been carefully assessed but the care planning process should cover wider care needs. Choices are only limited when it is absolutely necessary. EVIDENCE: Three client files were looked at. Each client had several different documents that provided information about their care needs. Information was good and provided specific guidance on how specific care needs should be met. Each client had a comprehensive assessment that covered areas of risk that is linked to behaviour. A list of likes and dislikes had also been completed. Each file had a monthly review which summarised events. This is a good system and provides an overall picture of what has happened over recent months. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 12 Where possible, clients have been involved in the care planning process. Several care plans had been signed by clients. A monthly evaluation provided details of discussions with a client and their agreement that one plan was no longer relevant. The plan had been removed from current documentation and put in a different section. One client talked about his care plan and explained that there were certain things he was not allowed to do. He said he knew the reasons and these were written in his file. Staff said they were involved in the care planning process. A relatively new member of staff said she read the care plans when she started working at the home. Most of the assessments and plans linked to behaviour and there was very little information which explained what help is required with personal care and daily living. There was evidence that one client was having problems with continence but a care plan was not available. Clients are involved in helping around the home and preparing and cooking meals but again there was no information about clients’ abilities in daily living tasks. The care plans should be broadened to make sure clients and staff are clear about how support should be given. At Woodhouse Cottage, one client file was looked at. Care plans covered a wider range of needs but there was very little change in the personal goals that had been set in October 2006. The assistant manager said other care plans and goal planning had been reviewed more thoroughly. A keyworker system is in place. Staff and clients talked about the keyworker role and everyone understood what responsibilities keyworkers had. Some clients are not able to leave the home unaccompanied and require up to two staff to escort them in the community. Some clients cannot be left alone with females. Any limitations that are imposed have been formally assessed and care plans to manage risks have been introduced. Some clients only have access to a limited amount of money. For example one client is given a maximum of £2.00. This again is very clearly documented and has been discussed and agreed with their community nurse. Client meetings are held regularly. Meeting minutes confirmed that different topics relating to the home were discussed. Recent topics included activities, menus and cleaning the house. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients generally have a decent lifestyle and this will be further enhanced when there is an increase in the level of activities. EVIDENCE: Daily records were looked at and these contained information about clients going out with staff support. The home has a car which is used to take clients out. Staff said clients did get opportunities to go to the local and wider community, and used different leisure services, although they thought clients could benefit from more organised activities. One client who does not receive any form of day care during a four-week period had been to the pub, cinema, church, local shops and a drive in the car. Clients at Woodhouse Cottage tend to have more opportunities to go out. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 14 One daily record identified that a relative had requested staff to accompany the client to a specific activity. This was followed through as requested. Daily records did not contain much evidence of in house recreational activities. Management and staff had recently identified that the level of activities in and out of the home could improve. Three staff had been allocated to look at general activities and organise outings. A list of outings was displayed on the notice board and options had been discussed at the last client meeting. This is good practice and demonstrates that the management and staff team are monitoring quality and taking action to improve the service. Seven client surveys were received; five had been completed with support. Seven stated that they could do what they want but one stated they couldn’t on an evening or weekend. Clients are encouraged to be involved in daily tasks and this varies on their levels of independence. One client said he likes helping staff to cook. Another client said he tidies his room and he was cleaning his carpets with staff support. Two weekly menus were sent with the pre inspection material and these were varied and nutritious. Meals served during the inspection corresponded with menus. Any variations to the menu are recorded. Staff and clients said the food was good. Clients help staff in the preparation and cooking of meals. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to make sure healthcare needs are met. EVIDENCE: Each client had a healthcare record that identified when healthcare appointments were attended. Records for three clients were looked at and these confirmed that clients had regular health checks. One healthcare appointment had not been included on the health record but had been recorded in an incident report. It is important to record all appointments to make sure healthcare needs can be properly monitored. Staff and management have consulted healthcare specialists for advice and guidance. Relevant details were recorded and added to care plans if appropriate. Storage of medication and medication records were looked at. The storage was well organised and records were completed correctly. All staff that are responsible for administering medication have completed medication training. A self-administration risk assessment has been completed for each client. One Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 16 client had expressed a wish to administer their medication and staff had agreed that they could work with the client to achieve this goal, however, this had been identified several months ago and no action had been taken. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a service to people with very complex and diverse needs and because there are a large group of people living together, several who are potentially very volatile, this often results in violent incidents. The impact of this affects the quality of life for people living at the home. EVIDENCE: Clients said they talk to staff and the manager if they are unhappy. Client surveys stated that they know who to speak to if they are unhappy. One survey stated they go to the manager and staff, another survey stated that if they are worried they sit down with staff. Staff said they are comfortable talking to the management team and would talk to them if they had any concerns. The Commission has received a lot of notifications of violent incidents between clients. There have also been a lot of incidents of restraint. Records for restraint were looked at, and these had been completed with a full detailed account of events. Risk assessments and care plans clearly identify when and how restraint should be used. A monthly summary is completed for each client that identifies any incidents that have taken place. Generally the summaries were very good but one summary did not contain details of a key incident, although information was Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 18 available in the restraint file and on an incident form. The person who wrote the summaries did not sign them, therefore it was not possible from the summary sheet to establish the author. However, this appeared to be a one off because all other documentation was signed. During the inspection, a number of aggressive outbursts were observed, although none resulted in any form of restraint. Staff and the manager were seen to de-escalate potential volatile situations. Some clients were very threatening towards staff and staff responded calmly and confidently, and gave clear messages that behaviours were unacceptable. Clients were seen to provoke each other, and again staff appropriately intercepted. Staff spoke about managing aggressive behaviour and they all felt that they only ever used restraint as a last resort and generally behaviour was well managed. Staff also said they knew what they are doing and had a good knowledge of clients, and felt well supported by colleagues and management. Staff are dealing with violence and aggression on a frequent basis and it is important staff receive adequate training that gives them the knowledge and skills to deal with volatile situations. Staff are expected to complete a one day course and a four day course. Seven staff have not attending the four day course. The one day course is an in-house session that is facilitated by a member of the management team. There is course material but no current guidance that provides details of how in depth the training should be. The management team acknowledged that the training could vary greatly and agreed that some additional guidance would be beneficial. Several clients spoke about the difficulty in living with people that are violent and aggressive. Comments included, ‘some are always kicking off, others are always carrying on, it’s hard living with others, I get fed up with them, when other clients start kicking off or bully staff I walk away’. The registered provider and management team must look at client compatibility and the safety and quality of life of those clients that struggle to cope with the on going level of aggression. Financial records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. A bankcard was being held on behalf of one client. A financial audit had identified that this was not a safe system and changes were being introduced. This demonstrates that the organisation has systems in place to monitor clients finances and recommendations are acted upon. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes are clean, tidy and generally well maintained. An additional communal room would make a vast difference to how staff could deal with volatile situations. EVIDENCE: Tours of the buildings were carried out. All communal areas and bathrooms were visited and the majority of bedrooms were seen. The homes were clean and tidy. Decoration, furniture and furnishings were of a reasonable standard. A good system is in place for monitoring maintenance around the homes. Management and staff carry out checks and any problems are recorded. A maintenance worker covers all three units and carries out work as and when required. Two units had external doors with glass panels missing. These had been broken during incidents at the homes. Glass was removed for safety reasons Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 20 and the holes were boarded up. However, both had been broken several weeks ago and had not been replaced. As explained in the previous section, several incidents that disrupted clients took place during the inspection. The main unit, Carlton House, does not have a quiet communal area that clients can use. Several years ago, a small lounge was converted to an additional bedroom. It was said that this was a facility that is greatly missed. The high number of incidents and feedback from staff and clients are strong evidence that there are not adequate communal rooms. Carpets in some communal areas at Carlton House were worn. The manager had already identified that they needed replacing, a request had been sent to the organisation and they were waiting for approval for the work to go ahead. The flooring in a first floor toilet was stained and should be replaced. The hob in Carlton Cottage does not have any markings next to the dials for turning on and off the heat, therefore from looking at the hob it is not possible to determine if the rings are on or off. This poses a high risk and must be addressed. One person said this was one of the reasons staff don’t cook in the Cottage kitchen. There was an odour in one bathroom in Carlton Cottage. The Commission received a notification that a client’s bike had been stolen from outside the home. There is no appropriate storage for bikes, one was fastened to a tree and another was kept in the meeting room. Suitable storage should be provided so clients could keep their bikes safe. The home does not have a call system. Each staff member carries a two way radio at all times. Staff said they never work without having a radio. They said the system works well and they always feel safe. The laundry has industrial washing and drying equipment, the washer is fitted with a sluicing programme. Generally there were appropriate hand washing and hand drying facilities but in one bathroom there was no hand wash and in two areas there were no appropriate hand drying facilities. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team work well together and have a clear understanding of everyone’s roles and responsibilities. EVIDENCE: All clients spoken to and surveys were complimentary about staff and management. Comments included ‘staff are good, they help us do jobs, staff are friendly, staff are helpful, I like having staff around the clock, staff try to help me sort out my problems- after I feel better and more relaxed, staff treat me well and with respect, all staff at Carlton House are very nice, they listen to what you are saying if you are upset’. Client surveys stated that staff treat you well, six stated staff always listen, one stated staff sometimes listen. Staff had good knowledge of clients and were able to talk about their likes, dislikes, relatives, abilities and levels of support. Staff were very positive and thought the team worked well together, they felt safe and thought all staff understood their own and others roles and responsibilities. Everyone said the units provided a good service. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 22 Staff attend a handover at the beginning of each shift. A handover was observed and staff passed on information about each client and identified what tasks had to be completed. Staff were allocated to a unit and given specific tasks. The session was informative and well organised. Staff meetings are also held, although these have not been held on a regular basis. The minutes confirmed that they were used as good forums for discussion and passing on of information. The last inspection identified that staff must be supported and supervised. Supervision commenced after the last inspection and has since been offered regularly. One new member of staff said she had had a good induction and had shadowed staff, read care plans and was made fully aware of any risks. The organisation has produced an in-depth induction workbook for new staff. Two staff that started work a few months ago had started the induction books but had not completed them. A system should be introduced to make sure new staff have a satisfactory induction. Staff training records were looked at. Most staff have completed mandatory training which includes moving and handling, health and safety, fire safety and infection control. There were gaps in basic food hygiene training, therefore some staff that prepare and cook food do not hold the relevant qualification. Three staff have completed NVQ level 3 and one staff has completed NVQ level 2. Five staff have started an NVQ award and others are in the process of applying. Staff talked about the recruitment process and said they were made aware of the nature of the job before they started. Generally only one person interviews candidates, even though they may attend more than one interview. This does not meet equal opportunities standards. Two newly appointed staff files were looked at and these had all the relevant information that is required. The home is using a high volume of agency staff because they are short of staff. Posts have been advertised and the manager is hoping to appoint some new staff shortly. Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership and direction to staff at Carlton House and Carlton Cottage. The assistant manager provides clear leadership and direction at Woodhouse Cottage. However the management arrangements do not meet registration criteria and quality assurance systems are not effective. EVIDENCE: The registered manager has worked at the home for over ten years. He and an assistant manager have applied to start the registered manager’s award. The other assistant manager has completed the award. The management team work well together. As stated under the choice of homes section, the management of Woodhouse Cottage is not appropriate Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 24 because the registered manager does not have day-to-day responsibility for the running of the home. An assistant manager works at the home three days a week and carries out the management responsibilities of Woodhouse Cottage although he is not registered with the Commission. The registered provider must make sure proper management arrangements are in place. Daily records are completed at the end of each shift. Generally, there was sufficient information about what clients had been doing and any records for significant events were specific and factual. The Commission must be notified of any significant events; these are called Regulation 37 notifications. The home has sent regular notifications as required, however, there were two events which were not reported. The manager has since sent a notification for one of the events and agreed to send the other when some additional information had been received. At least once a month a senior manager or representative should visit the home and look at the general conduct, these visits are called Regulation 26 visits. A visit was completed in January and February 2007 but the previous visit was September 2006. The recent visits identified good practice and also identified areas for improvement. This demonstrates that the registered provider is monitoring the conduct of the home, although this has not been on a regular basis. The organisation has sent quality assurance surveys to relatives and clients. The surveys have been returned but then the information has not been analysed, therefore they are not effective forms of monitoring quality. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. Fire equipment was checked in September 2006. Carlton House Dispersed Scheme DS0000001432.V323694.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 2 29 X 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Carlton House Dispersed Scheme DS0000001432.V323694.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 YA1 Regulation 4, 5 Requirement The registered persons must look at how the homes operate and how they are managed. The services and facilities must be reviewed and clear guidance of how they will operate must then be produced. This should be in the format of a statement of purpose and client guide. All clients must have a signed contract/statement of terms and conditions. Where issues of capacity are evident, suitable arrangements must be put in place to safeguard clients. The cost of the placement and room allocated should be included. (Previous timescale of 23 August 2004 and 4th October 2005 not met.) 3. YA6 15 Each client must have a care plan that identifies how their social, personal and health care needs should be met. Client compatibility and the affects of living with volatile people must be looked at to see DS0000001432.V323694.R01.S.doc Timescale for action 30/09/07 2 YA5 5(1)(b) 31/05/07 30/06/07 4. YA23 13 30/09/07 Carlton House Dispersed Scheme Version 5.2 Page 27 if any improvements can be made. 5. YA23 18 All staff must receive adequate training to deal with violence and aggression. This relates to the four day course. There should be guidance for the one day course to ensure training is in sufficient detail. The two external doors must be repaired. (Carlton House and Woodhouse Cottage) The flooring must be replaced in the first floor toilet (Carlton House) The hob must be replaced. (Carlton Cottage) Appropriate outdoor storage must be provided so clients can store their bikes safely. 7. 8. 9. YA28 YA30 YA32 23 13 18 There must be adequate communal areas for clients (Carlton House) Hand washing and drying facilities must be appropriate to stop the spread of infection. There should be more staff that have undertaken a nationally recognised qualification in care. (NVQ level 2 or equivalent) All new staff must complete the induction programme. Food hygiene training must be provided to all staff that are involved in food preparation. There must be a registered manager that is responsible for the day-to-day management of all units. The registered manager must be suitably qualified. DS0000001432.V323694.R01.S.doc 30/06/07 6. YA24 23 30/06/07 30/06/07 30/04/07 30/09/07 10. 11. 12. YA35 YA35 YA37 18 18(1) 8 30/04/07 30/06/07 31/08/07 13. YA37 9 31/12/07 Page 28 Carlton House Dispersed Scheme Version 5.2 14. YA36 18 A quality assurance system must be introduced that measures the success in achieving the aims and objectives of the home. The registered provider must ensure regulation 26 visits are carried out at least monthly. 30/06/07 15. RQN 26 30/04/07 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. 4. Refer to Standard YA14 YA20 YA33 YA34 Good Practice Recommendations The level of recreational activity and community participation should continue to be developed. The agreement to support one client to self medication should be followed up. Staff meetings should be held at least six times a year. Two staff should be responsible for conducting staff interviews Carlton House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 House Dispersed Scheme DS0000001432.V323694.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!