Inspection on 05/09/06 for Carlton House Dispersed Scheme

This inspection was carried out on 5th September 2006.

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

The inspector 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 13 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 27/02/07

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 Karen Westhead Key Unannounced Inspection 5 September 2006 09:30 th Carlton House Dispersed Scheme DS0000001432.V307789.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.V307789.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.V307789.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) 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.V307789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Carlton House 10 residents Carlton annex 5 residents Woodhouse Cottage 6 residents Date of last inspection 4th October 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 residents with a learning disability and is spread over three properties. Carlton House has facilities for ten residents, an annexe within close proximity in the same grounds, provides additional accommodation for five residents 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 residents 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 manager. The annexe is purpose built, Carlton House and Woodhouse Cottage were previously family homes, which have been adapted. Carlton House and the annexe are situated in large grounds, a perimeter wall encloses these and the main gates are secured. Woodhouse Cottage accommodates residents who are more independent. Access is not restricted. The cottage has gardens to the front and rear. Both care homes are well served by public transport. Both sites provide car parking for visitors. The minimum fee is currently £1295.20 rising to £1513.95 depending on the needs of the resident. This fee includes all toiletries, hairdressing and chiropody treatment. Newspapers and magazines, which are not provided by the home, are paid for by the resident. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area e.g. medication or food provision and are known as random inspections. The visit was unannounced and carried out by one inspector. The inspector arrived at 9.30am and feedback was given at the close of the visit at around 5pm. A pre-inspection questionnaire was sent out to the home prior to the visit. This was subsequently returned and provided information about the home; records and procedures; staff and residents. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at the completed preinspection questionnaire, the number of reported incidents and accidents, the action plan submitted following the previous inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. A number of documents were looked at during the visit; some areas of the home were seen, such as bedrooms and communal areas. The inspector also spent time talking to residents and staff. Residents who were unable to comment on their experiences were observed. CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. Two residents completed their questionnaires whilst discussing the content with the inspector. Their views shared by the residents are contained throughout this report. At the time of writing this report no further responses had been received. What the service does well: Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 6 Residents who may wish to use the service are able to visit prior to making a decision about moving in. The arrangements are flexible enough to make allowances for residents who need to move in quickly or may need longer to make up their minds. The staff in the home are proactive in the way they make opportunities available for residents wanting to pursue educational placements and interests. Residents are able to live their lives in a way they choose and staff promote residents individuality. What has improved since the last inspection? What they could do better: There are some requirements, which remain outstanding from the previous inspection. • • • • • • Not all residents have a signed statement of terms and conditions. Not all care plans were up to date. A trip hazard at Woodhouse Cottage remains unresolved. Not all staff have received appropriate training. Not all staff are receiving one-to-one supervision. Fire safety procedures are not being adhered to. As a result of this inspection the following requirements were highlighted: • • • Risk assessments must reflect the needs of the residents. Work is required to make sure the home is safe and fit for purpose. Staffing levels must be adequate at all times to meet the needs of the residents. 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.V307789.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.V307789.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. People who may use the service and their representatives have the information they need to choose a home, which will meet their needs. However, not all residents had a signed contract, which tells them exactly what they can expect, once admitted and not all information is produced in a way, which is accessible to all. EVIDENCE: Following the last inspection, in October, the home has produced an up to date residents guide. Work had also been done to make sure all residents have a contracts, setting out the terms and conditions of their stay. Most of the contracts are held on individuals files. However, not all of them had been signed by the resident, if appropriate, or a representative/relative. It is recommended that more be done to make the information more accessible to residents who may have limited reading skills and understanding. Evidence was seen to show that residents have a needs assessment before coming to Carlton House and any additional information provided by other parties, e.g. Social Services is considered before residents are invited for a visit and trial stay. All of the current residents are funded through a local authority. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 9 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): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Residents are involved in decision-making about their lives and play an active role in the planning, care and support they receive. Some improvements are needed to make sure care plans accurately reflect the care required and risk assessments need to be more specific. EVIDENCE: The aims and objectives of all the homes acknowledge the rights of individuals to take control of their lives. Staff talked to the inspector about how they were able to promote the wishes of residents and gave examples of where decisions had been made by residents with their support. The majority of residents confirmed they did retain control over decisions, if they wanted to. Two residents shared their views that decisions were not always to their liking but they understood that their alternative choice was unrealistic and the outcome would not be good. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 10 Residents said they knew who their nominated worker was. Staff said they felt this worked in theory but not always in practice due to staffing levels and shift patterns. There was written evidence on some care plans showing what staff were doing to meet residents needs and any changes in the care delivered. However, there were also examples given verbally about the care needs of two residents and this had not been included in their care plan. One resident said he had read his care plan the previous day. He said the information was true and matched what he thought he needed to stay well. Risk assessments are in place, but can be improved. Some risk management is reactive rather than planned. The focus being to keep every one involved safe, rather than there being a review of residents needs and a structured plan being put in place. The use of restraint continues to be an area which requires constant monitoring. Not all residents said they agree with the use of restraint, their accounts were cross referenced with the records kept. All incidents in the home are recorded in full and statements are taken from any staff involved. Senior managers are currently monitoring the number of incidents. Not all staff had been trained in the use of restraint or the management of challenging behaviour. The organisation canvasses relatives and residents about their views on the care provided. This is analysed by the organisation and a report given to the home manager with ideas of how to make improvements if necessary. Practices are supported by company policies and procedures. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. Residents living across the scheme are able to make choices about their lifestyles. Staff help them develop life skills. Social, educational, cultural and recreational activities meet residents’ expectations. EVIDENCE: Residents said they are able to take part in a range of activities, which suit them. These were age, peer and culturally appropriate. Residents living at Carlton House and the annexe do have limitations on where they are able to go and whether they are able to go out unescorted. Residents at Woodhouse Cottage are more independent. However, activities are being organised to the satisfaction of residents. Staff showed an awareness of the need to enable younger adults to achieve their goals and follow their interests, this has resulted in a few residents signing on at local colleges and pursuing educational placements. Where needed, staff accompany residents to outside placements. Residents do make good use of the local community. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 12 Across the three homes, staff support residents to be as independent as possible. This includes residents taking responsibility for food preparation and cooking. The involvement of staff is determined by the individual skills and abilities of each resident. At Carlton House, for those residents who need support during mealtimes, including those who have swallowing difficulties, staff are available to assist. A mealtime was not observed during this visit but residents in each of the houses told the inspector that food was good, well prepared and plentiful and that they had enough time to finish their meals. They said meal times were flexible, apart from the main evening meal. Staff provide support and guidance to residents about the benefits of healthy eating. None of the homes employ a cook. Staff are expected to plan and provide meals as part of their role. This is well planned and the menu choices do reflect the choices of residents. Residents discussed the relationships they had with family and friends. They said they were supported to maintain links with others and helped to identify people that made them happy and those who might be detrimental to their welfare. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 13 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, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. The health and personal care provided is based on individual needs. Residents are treated with dignity and staff respect their privacy. EVIDENCE: Residents across the scheme have access to wide range of health care services. Residents are able to choose their own doctor and are registered with a local optician and dentist. A chiropodist visits Carlton House and the annexe on a regular basis. Staff attend appointments with residents if necessary. However, the homes policy on this reinforce the importance of treating residents with respect and dignity. Medication records were checked and were being completed properly. Residents who have the capacity are encouraged to keep and take their own medication. However, risk assessments have dictated that none of the current residents can do this. Only staff trained to do so give out and record medication. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Residents are able to express their views about the home. They have access to a complaints procedure and are able to raise concerns. Further training is required to make sure staff have sufficient knowledge to protect residents from abuse and harm. EVIDENCE: The home has a complaints procedure, which residents said they understood and knew how to make a complaint. The policies and procedures around the protection of residents are satisfactory but some staff have not been trained in this area. The policy makes it clear when incidents need input from other professionals such as community nurses or psychologists and who staff should contact. One adult protection issue had been raised at Woodhouse Cottage and was being dealt with in accordance with the homes policy. In discussion, staff demonstrated an awareness of the content of the policy and knew to report any suspicions to a senior member of staff. On the whole, residents said they felt safe and supported. Two residents discussed their feelings about restraint and how this affected them. The incidents they referred to were discussed with the manager as part of the inspection process and records kept were cross-referenced with daily records. One complaint had been received since the last inspection. The complainant was a member of the public, who had complained directly to the home about a Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 15 residents behaviour whilst in the garden. This had been dealt within in house and to the complainant’s satisfaction. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 16 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, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. The design and layout of each of the homes allows residents to live in a safe and comfortable place. Some maintenance requirements were highlighted. EVIDENCE: The homes provide a physical environment that meets the needs of residents. A rolling programme of redecoration takes into account the wear and tear of constant use. Residents can personalise their rooms. Residents showed the inspector around all of the homes. Not all bedrooms were seen as the occupants were either out, busy elsewhere or not willing to give access. However, all communal areas were seen. The following work is required: Carlton House: • The shower was out of use. This had been reported and the contractor was waiting of a part to be delivered. • The roof over the designated smoking area was leaking. • A broken window on the upstairs corridor needs replacing. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 17 Unwanted furniture being stored outside must be disposed of correctly. Checks must be made to make sure all fire extinguishers have been serviced within twelve months. • Carpets, which are stained or damaged, must be replaced. Woodhouse Cottage: • The broken flagstone has not been replaced and remains a trip hazard. • Damage to plasterwork needs to be repaired. • Fire doors must be kept shut. On the day of the visit one fire door had been propped open using a fire extinguisher. • An unpleasant odour was noted in one area of the home. (Identified to the manager.) The cause of this needs to be investigated and an action plan put in place. The homes were clean and tidy. • • Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 18 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, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to the home. Not all staff are sufficiently trained to support the residents being cared for so some care needs can be overlooked. A serious shortfall in the staffing arrangements during the night at Woodhouse Cottage was identified during the inspection. This was dealt with immediately following the visit and a letter was sent to the organisation raising concerns. EVIDENCE: Not all staff have received the appropriate training to deem them sufficiently competent in all areas of care. The training undertaken to date shows gaps in some important topics including adult protection, control and restraint and health and safety. Staff have not been supported to pursue external qualifications including NVQ’s. Recruitment procedures make sure all the necessary pre-employment checks are made before staff start work. The staff team covers a range of diversity and reflects the cultural and gender of residents across the scheme. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 19 Not all staff are receiving supervision on a one-to-one basis as required. Staffing levels in two of the homes were being maintained. However, at Woodhouse Cottage the night staff arrangements had been reduced because half of the residents had gone away on holiday. This did not take into account the needs of the remaining residents or their health and safety. No risk assessment had been completed despite there being a lone worker during the night. The staffing was inadequate and these concerns were shared with the manager at the time of the visit and a letter was sent to the organisation. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 20 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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. The manager and administration of the home is satisfactory. The organisation is offering added support to make sure the home makes improvements. EVIDENCE: The manager has relevant experience and is working towards the Registered Managers Award. The organisation has identified some areas of the home, which require improvements, such as record keeping and staff training and as a result of this additional senior support is in place. The homes are resident focused and generally work well with other agencies. The homes have a health and safety policy which staff were familiar with during discussions with the inspector. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 21 The organisation manages the finances and resources available to the manager. The manager is expected to manage these within the budgets set. Checks showed that records were being correctly maintained. However, there were some gaps in recording and documents were not always dated or signed. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 2 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 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 23 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. Standard YA3 Regulation 15 Requirement 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, 23 August 2005 and 4th October 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. Timescale for action 29/10/06 2. YA5 5(1)(b) 29/10/06 3. YA24 23(2)(o) 23(4) (Previous timescale of 23 August 2004 and 4th October 2005 not met.) Trip hazards must be attended 17/10/06 to. Fire safety precautions must be in place and maintained appropriately. 4. YA35 (Previous timescale of 4th October 2005 not met.) 18(1)(c)(ii) Suitable arrangements must be DS0000001432.V307789.R01.S.doc 29/10/06 Page 24 Carlton House Dispersed Scheme Version 5.2 in place to allow staff time to attend courses. (Previous timescale of 4th October 2005 not met) Staff of all designations must be supported and supervised at least six times per year. (Previous timescale of 12th April 2005 and 4th October 2005 not met.) The home must be kept as far as reasonably practicable free from hazards including fire safety. All residents must have an up to date risk assessment which details specific care needs. The home must be maintained in a way, which keeps it safe and fit for purpose. Bathing facilities must be maintained in working order. Staff must be provided with suitable training to make sure they have the necessary skills and knowledge to care for residents properly. Staff must have adult protection training. Staffing levels must be adequate to meet the needs of the resident group. Staff must receive supervision and support from senior staff. 5. YA36 18(2) 29/10/06 6. YA42 23(4) 29/10/06 7. 8. 9. 10. YA9 YA24 YA27 YA32 13(4) 23 23(2)(j) 18(1) 19/10/06 29/10/06 19/10/06 29/10/06 11. 12. 13. YA23 YA33 YA36 18(1) 18(1)(a) 18 29/11/06 05/09/06 19/10/06 Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations More work should be done to make sure information for residents is accessible and in a format which is easy to understand. Carlton House Dispersed Scheme DS0000001432.V307789.R01.S.doc Version 5.2 Page 26 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.V307789.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. 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. 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