CARE HOME ADULTS 18-65
Carlton House Dispersed Scheme 24 Wakefield Road Rothwell Haigh Leeds West Yorkshire LS26 0SF Lead Inspector
Karen Westhead Unannounced Inspection 4th October 2005 09:20a Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 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.V249134.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V249134.R01.S.doc Version 5.0 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) 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.V249134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Carlton House 10 service users Carlton annex 5 service users Woodhouse Cottage 6 service users Date of last inspection 12th April 2005 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 adults with a learning disability and is spread over three properties. Carlton House has facilities for ten service users, an annexe within close proximity in the same grounds, provides additional accommodation for five service users and Woodhouse Cottage is registered for six adults. The one double bedroom, at Carlton House, is used as a single room thus admitting to a maximum of nine residents. Woodhouse Cottage is located three miles away. It is a satellite facility, which is staffed seperately, with Robin Staincliffe retaining oversight as manager. Carlton House and the annexe are situated in large grounds, a perimeter wall encloses these and the main gates are electronically secured. Woodhouse Cottage accommodates service users who are more independent. Access is not restricted. The cottage has gardens to the front and rear of the property. Both care homes are well served by public transport. Both sites provide car parking for visitors. The annexe is purpose built, Carlton House and Woodhouse Cottage were previously family homes, which have been adapted. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all regulated care homes. This was the second inspection of this home for the 2005/2006 inspection year. The inspection, which was unannounced, was undertaken by one inspector. The visit started at 9.20am and finished at 4.10pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 12th April 2005. At that time there were eleven requirements and one recommendation was made. Not all requirements have been addressed. Seven of the eleven remain outstanding. Some improvements were noted with regard to the recommendation made in April 2005 involving the use of terminology and language in care records. Additional requirements and recommendations were made during this visit. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and the manager across the three sites. A number of documents were inspected during the visit; some areas of each of the homes were seen, such as bedrooms and communal areas. All staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. In addition, information leaflets were given to residents with a brief description of the CSCI function and details of how to contact the lead inspector. Feedback about the findings from the inspection were given to the manager at the close of the visit. What the service does well:
The home provides some information in pictures and symbols to assist people with limited communication skills. In particular the complaints procedure has been modified in this way. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 6 Residents, if they are not admitted on an emergency basis, are given the opportunity to visit Carlton House for a series of introductory visits. This is arranged over a predetermined length of time, in accordance with individual circumstances. This is a positive way to ensure residents are able to make an informed choice about whether they move into the home. It also gives staff the opportunity to carry out a more comprehensive assessment and ensure they are able to meet the residents’ needs. The home has a system of risk management, which is designed to minimise risks yet not place unnecessary restrictions on residents. The home tries to promote a good balance between educational, social and recreational activities. However, some more work is required to ensure there is sufficient variety available. Residents are given ample time to relax in their own rooms. Residents are afforded privacy, choice and dignity. Keys are available for individual bedrooms. Staff are sensitive to the needs of residents, they knock on doors before entering and were seen to give residents space and time to make decisions affecting them. What has improved since the last inspection? What they could do better:
The home needs to provide more information, by way of a residents’ guide. This should include clear details about the home and give an overview of the services provided.
Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 7 Residents could be more involved with the development of personal care plans, which aim to map out their individual needs and expectations. This must be evaluated and reviewed regularly. The standard of documentation seen throughout varied greatly and more effort needs to be made to ensure all staff are familiar with the task and that their work is overseen until a higher level of competence is noted. All residents must have a contract, which states the terms and conditions between them and the home. Where there are difficulties with understanding, the home should seek third party advocacy where appropriate. Staff of all designations must be well supported and supervised at least six times per year. This is still not being provided consistently throughout the scheme. The inspector noted a number of instances where fire safety was being compromised. The fire equipment checks had lapsed at Woodhouse Cottage and a fire extinguisher was being used to prop open a fire door, which was fitted with a self closing device in case of fire. At Carlton House, fire doors were found to be wedged open. These issues were highlighted during the last inspection also and must be addressed as a matter of urgency now. In addition, the grounds at Woodhouse Cottage and Carlton House are being neglected. At Woodhouse Cottage, two flags to the step leading to the back garden need replacing to address the trip hazard. There is also an outstanding matter relating to the water supply at Woodhouse Cottage. Recommendations from the contractor are still to be put in place. At Carlton House the driveway is beginning to break up and the gardens need attention. Some staff commented on the low budget available for food provision. This was discussed with residents, staff and the manager. There is a difference of opinion in the staff group. The inspector did not receive any adverse comments from the residents spoken with. However, this matter should be explored by senior managers, to ensure the correct measures are in place. The linen being used in the dining room must be appropriate and care should be taken with the laundering of these items. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 8 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 Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 9 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.V249134.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. The level of care and support for residents remains good despite the lack of some fundamental records. Residents are offered ample opportunities to visit the home, prior to admission, to assist them in their choice of home. Unless the admission is conducted as a result of a crisis or emergency situation. EVIDENCE: Throughout the inspection visit the inspector was talking and interacting with residents across all three sites. Their level of satisfaction with the care provided ranged from those who were generally happy but had future plans to move on and those who were content at the home and wished to stay for the foreseeable future. No complaints were raised with the inspector. The issue around the completion of care plans and records continue. The manager acknowledged that additional work was required. The inspector viewed a random selection of files. Many did not contain up to date contracts, plans of care, evaluation or review. Work is also required to develop care plans in consultation with residents. A residents guide is needed, which can be used in conjunction with other documentation. The complaints procedure has been modified using pictures and symbols. This method could be used in the residents guide to assist people with limited communication skills. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 11 The admission procedure for planned admissions is good. The procedure allows for residents and their families, if appropriate, to visit the home on several occasions. The visits vary in duration and the timescale is determined on an individual basis. However, the usual plan is for residents to share meals and leisure time at the home to familiarise them with the routines and give them the opportunity to meet other residents and staff. The staff see this as a two way process. They take the opportunity to assess the needs of the resident and ensure the home can cater for any specialist requirements as well as the general care needs of the person. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10. Work is required to develop care plans in consultation with residents. Residents are offered the advocacy and assistance to make real life choices. Information held in the home is handled appropriately and staff are bound by procedures around confidentiality. EVIDENCE: A random selection of files were seen. The information held varied and the manager acknowledged that additional work is required to bring the standard of documentation to an acceptable level. Some staff are better than others at recording events and incidents. The senior management team need to assess this and provide additional support as required. The interaction between staff and residents is improving. This should be developed to help maximise the involvement of residents. Daily recording gave a good picture of what was happening and the handover sessions between staff on duty are comprehensive and appropriate. Written evidence and verbal feedback from residents suggests that they are able to express their views and given support, sometimes through advocacy, to ensure their rights are respected. Most residents are able to manage their
Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 13 finances with appropriate levels of assistance and support from staff or third parties. There have been a number of meetings and the involvement of other agencies to ensure the protection and safety of residents within the home. The manager has addressed the issues raised in a constructive manner and taken the necessary steps. The situation is being monitored and the manager and staff team is working in an open and proactive way with the appropriate agencies, including adult protection and CSCI. Staff spoken with were aware of the need to keep information confidential. They spoke with knowledge about adult protection matters and the potential for abuse. All staff sign a contract of employment, which has a statement about confidentiality, and staff are taken through this on their induction training. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 15, 16 and 17. Educational, social and recreational activities provide a good balance and allow the opportunity for personal development. Family links are maintained and residents are able to develop intimate and personal relationships with people of their choice where appropriate. Assistance and guidance is provided in these areas, often involving advocacy and other professionals. Efforts are made to provide a balanced and healthy diet. However, the inspector found there was a difference of opinion and this should be explored further within the home. EVIDENCE: The manager has identified the need to enhance existing leisure and educational facilities. A member of staff has been identified to undertake the role and has been given a budget and flexibility to work alongside residents. Written evidence on file and in the daily notes showed that residents were maintaining outside links and being given help, reassurance and assistance to engage in meaningful and fulfilling relationships with people of their choice. All residents have a key to their rooms. The inspector noted that residents respected each others belongings. The inspector was given permission to
Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 15 inspect bedrooms by residents who were at home. In most cases the resident accompanied the inspector. Residents are involved in household tasks and this is distributed on a rota basis. Residents who are reluctant to engage are given support. Some residents were proud of their achievements and enjoyed showing the inspector around their home and bedroom. Some staff commented on the low budget available for food provision. This was discussed with residents, staff and the manager. There is a difference of opinion in the staff group. The inspector did not receive any adverse comments from the residents spoken with. However, this matter should be explored by senior managers, to ensure the correct measures are in place. The food planning, purchasing and preparations seem to include resident wishes. However, staff should remain mindful about the need to provide a healthy diet and a variety of dishes. The dining area has been greatly improved following an extensive refurbishment. The linen being used on the day of the visit was not well presented and did not fit the tables. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Residents receive personal support in the way they prefer. None of the residents require manual handling to assist with bathing. Residents are able to go to bed and get up when they wish. Residents have a designated key worker and this provides continuity and consistency for the resident. EVIDENCE: None of the current resident group requires specialist equipment to assist in their personal care. On arrival at the home the inspector found that residents, who required assistance with shaving and grooming, were being dealt with in a quiet and discrete manner by a male carer. Residents commented on their lifestyle and confirmed that they were able to ‘please themselves’ with getting up and going to bed. One resident, who got up after lunch, said they preferred to have a lie in and that staff were ‘cool about it’. Residents spoken with were familiar with the key worker system and commented on the advantages and disadvantages of the set up. On the whole residents said they preferred having a nominated person to speak to. They thought the system fell down when staff were on annual leave or away from the home for lengthy periods.
Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 17 Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 As noted at the last inspection, a significant number of incidents, resulting in a form of restraint being used, is an ongoing matter for the manager and organisation to consider. This issue must be continually monitored to ensure the use of restraint is reserved as a last resort and used appropriately. Despite this, concerns and complaints are dealt with promptly and appropriate action is taken to ensure the welfare and protection of residents. EVIDENCE: Records were examined to check the number of times restraint has been used. All incidents and accidents were recorded in full. Three incidents, involving residents, had been referred to the adult protection team and an investigation was ongoing. At the time of the visit there had been no formal complaints made at any of the homes. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 28. All residents have a single room, which is furnished according to their needs, wishes and preferences. Communal areas in all the homes are accessible, comfortable and well furnished. Externally, the grounds need attention. Fire safety procedures are not maintained and could compromise the health and safety of people in the home. EVIDENCE: All the communal areas were seen. The inspector also inspected the bedrooms of residents who were at home and gave permission. All rooms seen were decorated to a satisfactory standard and were furnished appropriately. Levels of cleanliness were found to be good. An issue in the shower room has now been resolved. Residents reported there being ample hot water and that the bad smell from the drains had been stagnant water and this was no longer a problem. It would appear the shower room is used regularly as the inspector was unable to assess the effectiveness of any repairs as the shower was in use throughout the visit. Externally, the grounds to all three sites need attention. The gardens are looking unkempt and overgrown. At Woodhouse Cottage, the flagstones have come away, on the steps leading into the back door and need replacing to
Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 20 remove a potential trip hazard. At Carlton House the driveway is lifting and becoming uneven. The continued wedging and propping open of fire doors remains an issue in the homes. This practice must stop as it compromises the health and welfare of people in the home. This was pointed out to the staff on duty and action was taken. However, this practice continues to be highlighted. There is an outstanding matter relating to the water supply at Woodhouse Cottage. Recommendations from the contractor are still to be put in place. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36. Staff have clear roles and responsibilities. Staff are in need of more regular support and supervision. A good level of training opportunities are available. However, the organisation must ensure staff are able to attend courses by providing sufficient staff to cover in their absence. EVIDENCE: The scheme manager said that overall the staffing levels were good and that most posts were now filled. The deputy manager took over the management of Woodhouse Cottage several months ago and this arrangement was working well. The inspector was told by staff that morale was good. Throughout the inspection staff were seen carrying out their duties in a confident, competent and pleasant manner. The resident group can present some challenging situations. These were dealt with calmly and professionally by the staff on duty. The inspector spoke with staff in private and in groups. They spoke frankly about their work and the motivation to do the job. They shared a common outlook and spoke enthusiastically about their responsibilities. Staff were relieved that they had managed to sign up to undertake NVQ training after a longstanding issue had prevented them from continuing or reinstating their learning. Staff confirmed the organisation had ‘got its act together’ with regard to regular training events. However, they were at times
Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 22 frustrated by the fact they could not attend if there were insufficient staff to cover their shift whilst absent. Staff are not receiving regular and consistent supervision from their managers. This has been a regular comment in inspection reports previously and must be addressed. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 43. The homes are well run and residents were aware of the management structure. The homes policies and procedures are written in a way, which is resident-focused and protects their best interests. Some practices compromise the health and welfare of residents. EVIDENCE: The manager oversees all three sites. The furthest house, Woodhouse Cottage is managed by the deputy, who has the autonomy to run the home on a daily basis and feedback to the manager on a weekly basis. The fire records were checked. At Woodhouse Cottage the manual testing had not been carried out since 14th September 2005 and a fire extinguisher was holding a fire door open. The fire door had a self-closing device which is activated should a fire break out. At Carlton House, fire doors were found to be propped open. This was pointed out to the manager at the time and immediate action taken. However, this practice seems to be the norm and must cease. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 24 Risk assessments are carried out and action taken to reduce risks. These must be reviewed regularly and amended as required. The actions taken appear to promote independence rather that impose undue restrictions on peoples’ lifestyles. The organisation has adequate insurance cover in place. Senior managers within the organisation have a business plan and managers in the home are expected to contribute to the formation of this. Managers present their budget forecasts and discuss the needs of each home as part of the overall financial plan. At the time of the visit the manager did not raise any problems with the financial viability of the three sites when asked. Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X 2 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 X X 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Carlton House Dispersed Scheme Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X 2 3 DS0000001432.V249134.R01.S.doc Version 5.0 Page 26 YES Are there any outstanding requirements from the last inspection? 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 2 Standard YA1 YA3 Regulation 5 15 Requirement The registered person must produce a resident’s guide. The home must be able to demonstrate that it can meet the individual needs of the residents admitted to the home through evaluation and review. Residents need to be more involved in the process. (Previous timescale of 12th April 2005 not met.) All residents 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 residents. (Previous timescale of 23 August 2004 not met.) The registered person must ensure that food provision is adequate. Linen used in the dining room must be fit for purpose and presented appropriately. Externally the grounds must be maintained. Trip hazards must be attended to. Fire safety precautions must be
DS0000001432.V249134.R01.S.doc Timescale for action 05/12/05 05/12/05 3 YA5 5(1)(b) 05/12/05 4 YA17 16(2)(i) and 16(2)(e) 05/12/05 5 YA24 23(2)(o) and 23(4) 05/12/05 Carlton House Dispersed Scheme Version 5.0 Page 27 6 7 YA35 YA36 8 YA42 in place and maintained appropriately. 18(1)(c)(ii) Suitable arrangements must be in place to allow staff time to attend courses. 18(2) Staff of all designations must be well supported and supervised at least six times per year. (Previous timescale of 12th April 2005 not met.) 23(4) The home must be kept as far as reasonably practicable free from hazards. Fire safety records must be kept up to date. (Previous timescale of 12th April 2005 not met.) 05/12/05 05/12/05 05/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carlton House Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Dispersed Scheme DS0000001432.V249134.R01.S.doc Version 5.0 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. 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!
