Inspection on 11/09/08 for Carlton Lodge

This inspection was carried out on 11th September 2008.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carlton Lodge 18/08/09

Carlton Lodge 12/09/07

Carlton Lodge 26/09/06

Carlton Lodge 12/01/06

Carlton Lodge 18/05/05

Carlton Lodge 12/10/04

Carlton Lodge 03/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOME ADULTS 18-65 Carlton Lodge 28 Carlton Street Normanton West Yorks WF6 2EH Lead Inspector David White Key Unannounced Inspection 11th September 2008 09:00 Carlton Lodge DS0000006171.V371813.R02.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 Lodge DS0000006171.V371813.R02.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 Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Lodge Address 28 Carlton Street Normanton West Yorks WF6 2EH 01924 223652 01924 227516 care@haptoncarehomes.co.uk 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) Hapton Care Homes Mr John L McIntosh Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2007 Brief Description of the Service: Carlton Lodge provides personal care for nine younger people with learning disabilities. The home is in Normanton, close to the town centre and all local facilities and shops. The home is close to a main bus route, rail station and the M62. Carlton Lodge has a small walled garden. People living at the home are all provided with single bedrooms, which they can personalise. The current individual fees for September 2008 range from £690.29 to £1804.88 per week. Information about the home is available to people via the statement of purpose, service user guide and the last inspection report, which are available in the home’s reception and are given to people who enquire about living at the home, and to people who currently live at the home. These documents also give people information about the Commission for Social Care Inspection. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. The Commission for Social Care Inspection 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. More information about the inspection process can be found on our website www.csci.org.uk We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations-but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 11th September 2008. The visit lasted from 9.00 until 15.30. The purpose of the visit was to make sure that the home was operating and being managed in the best interests of people living there. Information has been used from different sources for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on an Annual Quality Assurance Assessment questionnaire. Surveys returned from three people who live at the home, a social care professional and a health professional who both visit the home. During the visit time was spent talking to people who live at the home, care staff and the deputy and assistant manager. We observed staff caring for people in communal areas, looked at various records relating to care, staff, and maintenance, and looked at some parts of the building. The deputy manager was available for most of the site visit and the findings were discussed with her and the assistant manager at the end of the inspection. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Some links have been made with outside agencies to improve employment, educational and leisure opportunities for people who live in the home although further improvements need to be made. People are more involved in decision-making about the menu options on offer. This helps in making sure that people receive food that they enjoy to suit their individual tastes. The home now has a minibus that is equipped with adaptations so that people who use wheelchairs or have mobility problems can use this transport and have access to local attractions and other places of interest. The hallway and both lounges have been re-decorated to improve the comfort and pleasantness of the living environment. More re-decoration work is needed and this has been planned for. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 7 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 Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 8 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 Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 9 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): 1 and 2. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s needs are properly assessed before their admission so both the person and the service could feel confident that the placement was suitable. EVIDENCE: The statement of purpose and service user guide are available to people who are thinking about moving into the home and their relatives. These provide information about the care and services on offer at the home. People living at the home who returned surveys said that they are given enough information about the home. The admission process involves the manager or deputy manager visiting people in their own environment beforehand to carry out an assessment of the person’s needs and this forms the basis of the person’s care plan. More information is obtained from other sources such as placing authorities to support the home in their decision-making about whether they have the skills and resources to meet the person’s needs. People who are thinking about moving into the home and their relatives are invited for a visit before any decision is made about whether they move into the home on a permanent Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 10 basis. One person said, ‘I had a look around and had time to decide before I moved in’. Carlton Lodge DS0000006171.V371813.R02.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 and 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s care is generally well planned, recorded and delivered. Some aspects of people’s care including risks to individuals could be better monitored so that any changing needs can be identified and acted on sooner. EVIDENCE: Each person has a care plan that describes their individual needs and how these are to be met. The care plans focus on various aspects of daily living and detail how the person wishes to be supported with their needs where this is possible. The care plans explain such things as how best to communicate with person, their food likes and dislikes, activity preferences and how people wish for any inappropriate behaviour to be managed. Several of the people who live at the home have communication difficulties so discussion around care planning issues was difficult. However, some of the Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 12 care plans are written as told by the person receiving the support and this indicates that some attempts have been made to involve people in decisionmaking about their care where this is possible. A survey returned by one person living in the home said, ‘I enjoy living here and feel all my needs are met’. Another said, ‘I like to make my own choices and these are respected by staff’. A health professional survey commented ‘the home supports people to live the life they choose’. The deputy manager said that the placing authority is now carrying out annual care plan reviews and these are recorded. The majority of staff have worked at the home over a number of years and so know the people who live at the home well. This has helped them to get to gain a good understanding of how each person communicates through verbal and non-verbal means in order to meet their needs. Individual risk assessments were in place to identify any risks to people in their daily lives. This included information such as risks from people making their own drinks and showed how decisions have been made where people could be restricted in what they can do. One person had recently moved to the home from a nearby home that was owned by the same provider. The care planning documentation from the previous home was available but had not been updated to reflect the person’s needs in their new environment. The care records contained information that this person had become unsettled shortly after moving into the home and this had led to deterioration in the person’s behaviour. However, risk assessments in relation to this aspect of the person’s care had not been updated to look at possible reasons for the behaviour and any potential risks to the person or others from this behaviour. Throughout the day of the visit staff were seen to involve people in decisionmaking where possible. Staff were observed being respectful in helping people to maintain their dignity. The deputy manager said that advocacy services had been accessed to support one person who needed assistance with decisionmaking. Senior staff have handover periods between shifts. This information is then passed on to other staff. A communication and message book is also used to keep staff informed of any changes. Planned appointments are recorded in a diary. Carlton Lodge DS0000006171.V371813.R02.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, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Some improvements have been made to enable people to have more opportunity to pursue their leisure and recreational interests although this has been limited because of staffing issues and further improvement is needed. EVIDENCE: People’s care records include information about their preferred activity choices. Some people attend educational services outside the home. One person attends school throughout the week and two people go to a local college. People said they do what they want with their time. There are in-house activities such as painting, cooking and local outings in the minibus. The home now has a minibus with adaptations and this has helped in making sure that people with mobility problems have the same opportunities as others to go out in the minibus on outings. The registered provider pays for each person to Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 14 have one week’s holiday or equivalent each year. One person said they had enjoyed a holiday abroad, another said they were looking forward to a week at the seaside. Some people instead of having a week away prefer to have day outings. One person said, ‘I enjoy visits to the local pub’ whilst others visit the local shops. Some people had attended a fancy dress party at a social club in Leeds earlier that week and attempts are made to take people to the local social club on a weekly basis. People have the option of having reflexology sessions at the home although there is an additional charge for this service. At the previous inspection visit there were concerns that people had limited opportunities to participate in meaningful activities. There was evidence that the home has taken some steps to try and rectify this although further improvement is needed. The home has established links with the ‘Stars in the Sky’ social group and some people who live at the home have become members of this group. Another person expressed a wish to find voluntary work and the home have contacted an employment agency and supported the person to complete an application form. The home has also tried to establish links with the ‘Back in Touch’ employment agency to look at possible work opportunities for people. The deputy and assistant manager said that there had been limited opportunities for people through this because of the lack of suitable positions. They also said that local day service placements were difficult to access. The service is planning to continue to look at alternative day care and educational facilities both in and out of the local area. Whilst attempts have been made to improve people’s educational, employment, social and leisure opportunities it was evident that the current staffing levels are impacting on this happening. People who live at the home felt ‘frustrated’ that they could not go out more. One person said, ‘we hardly go out at the moment’. Another person commented ‘I enjoy going out and would like to go out more’. A staff member also commented that ‘the lack of staff is preventing people from getting out’. The service accommodates people with complex needs and behaviour that challenges the service. People said, ‘it can get noisy at times’. At the time of the visit a number of people could be seen sat around the home with staff. Whilst some people may choose this option others said they preferred to be ‘doing more’. The deputy manager understood that the impact of noise and lack of opportunity to spend time out of the building could impact on people’s behaviour and said that the impending recruitment of some new staff should help to address this issue. People are encouraged to maintain relationships with their family and friends. Some people visit their family at home and are supported by staff to do this. There have been some changes to the mealtime choices at the request of people who live at the home. The menus show that there are choices at mealtimes and healthy food options are available. One person was on a low fat diet and there were specific instructions about daily allowances and these were being followed. Staff have records of people’s food likes and dislikes to make Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 15 sure that personal preferences can be followed. People living at the home said that they enjoy the meals that are provided. Staff and people living at the home were seen eating their meals together. Staff said that some people do cooking and baking with staff. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People receive the support they need although improvements could be made in the way some aspects of people’s health needs are met and monitored. More attention could be given to make sure that people’s privacy and dignity is maintained. EVIDENCE: The support that people need is recorded in their care plans so that staff are aware of these. Staff provided personal support to people in private. During a tour of the environment one person’s bedroom window had no curtains. This meant that people could potentially see into the person’s bedroom from outside. Staff explained that there had been an incident in which the person had torn the curtains down and that this behaviour occurred regularly. However, although staff said that the person’s behaviour had been settled for the last week the curtains had not been put back up. They explained that they were planning to put some more curtains up and said that in the meantime the Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 17 person got dressed and undressed in the bathroom. In another bedroom the person’s bedroom door would not fully close. Both issues needed dealing with in order to maintain the privacy and dignity of the people concerned. Information received from the manager of the home shortly following the inspection visit indicated that both of these matters had been addressed and actions were being put in place to deal with these issues. Each person has a (GP) General Practitioner and access to dental and chiropody services. A survey returned by a GP said that the home always sought advice when needed. The care records showed that staff had supported people to attend appointments and healthcare information is recorded in the care plans about why people are attending appointments and outcomes from these. Sometimes appointments had been cancelled by the hospital or if the person who had the appointment was too unwell to attend. In these cases alternative appointments had been made. This helps in making sure that everyone is aware of people’s health needs and how these are to be met. Concerns about people’s health had been referred to the GP at an early stage so that people could receive the appropriate type of support. Some care plans were in place to monitor people’s weight. However, the care records showed that this was not being done on a regular basis. One person’s care plan stated that weight needed to be regularly monitored but this had not been done since March 2008, despite the person having previously put a lot of weight on in a short space of time. Other care records and discussion with staff also confirmed that people’s weight is not being regularly monitored. The care plans for weight also gave no indication as to when concerns needed to be referred to the GP for advice and guidance. A social care professional survey said, ‘I had concerns about how people’s weight gain had affected their mobility and had to insist that advice was sought about this’. As previously mentioned in this report under the heading of Lifestyle, more consideration needs to be given about the impact of people having limited opportunities to go out on their mental health and behaviour. Staff who handle medication on behalf of people are trained to do so. Systems are in place for the receipt, recording, storage, handling, administration and disposal of medications. Medication records were up to date and a random check of the controlled drugs supply tallied with the records. None of the people who are currently living at the home administer their own medication. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s concerns are listened to and acted on and systems are in place to safeguard people from abuse. EVIDENCE: The home has a complaints procedure that details the stages and timescales for the process. Surveys received from people who live at the home all said that people know who to speak to if they are unhappy and commented that staff treated them well and acted on what they said. One comment was ‘there is always someone I can talk to if I feel down’. The home had received one complaint and this had been logged and investigated. A letter had been sent to the complainant about the outcomes from this. A complaint had been made to the local authority about noise at the home and management from the home have attended meetings with the complainant and local authority about this. This matter has now been satisfactorily resolved. All the staff receive training about abuse awareness. There is also a policy and procedure in place for staff to follow if abuse is suspected or has occurred. Staff spoken to knew their responsibilities in reporting such matters to the management without delay in all instances. Other training around physical and verbal aggression is given to staff and this is updated as needed. This helps in Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 19 making sure that appropriate actions are taken by staff to keep people safe from harm. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 20 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 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is clean, comfortable and meets the needs of people who use the service. EVIDENCE: The accommodation is over two floors and can only be accessed by stairs, so people with mobility problems would need to have a bedroom on the ground floor if staying at the home. There is ramped access to and from the home to support people with mobility problems. The home has two communal areas where people can sit and watch television if they choose. People have individual bedrooms that are personalised. There are a sufficient number of bathrooms and a walk-in shower facility to meet people’s needs. One person at the home said, ‘I like my bedroom it is bright and has a lot of space’. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 21 Some parts of the home have been re-decorated since the previous inspection visit. This includes the hallway and both lounge areas. Re-decoration needs to be undertaken in a number of other areas of the home and this is planned for in the maintenance programme. During a look around the environment one person’s vinyl bedroom flooring had torn and this was discussed with the management who said plans are in place to address this issue. The home was clean and tidy and there were no odours. There are separate kitchen and washing facilities and staff were seen to be following food hygiene and infection control procedures. Appropriate hand washing facilities are available. Surveys returned by people at the home all said that the home was kept fresh and clean as did a social care professional who visits the home. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 22 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): 32, 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People receive good support from staff who have the training they need to meet people’s needs. Improvements in staffing levels would help in making sure that people’s needs are fully met. EVIDENCE: Staff are committed towards meeting people’s needs and are flexible in covering shifts at short notice. A social care professional said, ‘the majority of staff work hard to care for people living at the home and are pleasant’. The assistant manager said that there is usually 5 staff on duty in a morning, 5 in an afternoon and two waking staff at night to support nine people with complex needs. The manager, deputy manager and assistant managers are additional to the staffing numbers through the day. A manager is on call at evenings, weekends and all other times. Some staff have recently left the Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 23 home and on the day of the visit three new staff were having induction. One staff member is currently allocated to do cooking duties, one cleaning duties and another does the laundry. One member of staff is responsible each weekday to drive one person to school in Leeds. The majority of people who live at the home need at least 1:1 support whilst some people require two staff to support them with certain tasks. None of the people who live at the home are able to go out without staff support. People living at the home said ‘there are not enough staff at times. We don’t get much opportunity to go out although we enjoy it when we do’. A staff member commented ‘ the lack of staff means that people do not go out a lot’. This person also said that staff doing the cooking, cleaning and laundry duties meant there was less time to spend with people living at the home. People in the home said they felt ‘frustrated’ at not being able to go out much because of the lack of staff. The staffing issue was discussed with the deputy manager who said that three staff and a driver have recently been employed and will start work once the necessary checks have been satisfactorily completed. There are also plans to recruit a cook and an extra member of staff to work between 10am and 6pm to encourage more opportunity for activity. New staff are only confirmed in post following satisfactory police checks. Three staff files that were looked at contained evidence that application forms had been completed and references obtained as part of the recruitment process. However, in one case a verbal reference had been taken and whilst this had been recorded this had not been followed up with a written reference. This issue needs addressing to confirm the referee’s identity in order to make sure that people are not at any risk from unsuitable workers. The majority of staff have either completed or are doing the National Vocational Qualification (NVQ). This helps to ensure that people are receiving care from staff with the right skills and knowledge. Staff said that they receive good training to support them in providing care to people. As seen at the time of the site visit, new staff have a full induction before they are expected to carry out any tasks they are unsure of. Staff receive training in a range of safe working practices as well as other specialist training such as de-escalation techniques in managing behaviour that can be challenging to the service. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 24 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 and 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is well run and there are systems in place to improve the service and keep people safe. EVIDENCE: The registered manager has the necessary experience and qualifications to run the home. Staff said that the manager has an ‘open door policy’ if they have any concerns. One staff member described the manager as ‘patient and tolerant’. Another staff member said ‘this is the best care home I have worked in, the manager is excellent’. A social care professional survey commented ‘the manager is respectful towards people at the home’. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 25 The home has carried out their annual survey and received comments from relatives, health and social care professionals. Comments from these were seen and were mostly positive. One relative commented ‘the service is top notch it couldn’t improve’. Other comments suggested that the home could benefit from more re-decoration. A director from the company visits the home weekly and makes a monthly report of their findings and any actions to be taken. Meetings are held with people who live at the home and staff so that they have an opportunity to be involved in the running of the home. The service still holds the Investors in People award for the care and services they provide to people who use their service. The self-assessment form completed by the home prior to the inspection visit indicated that all the required maintenance and servicing of equipment were up to date and the records looked at confirmed this. The Portable Appliance Testing (PAT) of electrical appliances in the home is now overdue. The deputy manager said that the service were aware of this and had arranged a date for the testing to be carried out. Staff receive a range of health and safety training so that they are up to date about safe working practices. During a look around the environment one person’s bedroom door was unable to fully close. This could have potential fire safety implications if the door needed to be closed in the event of a fire. The deputy manager agreed to address this matter as soon as possible. Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 26 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 3 X X 2 X Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA18 Regulation 12 Timescale for action Measures must be taken to make 11/10/08 sure that all bedrooms are kept private at all times so that people from outside can not see into the bedrooms. This will help to maintain people’s privacy and dignity. Where potential risk is identified 11/11/08 about a person’s weight, this must be properly monitored. Care plans must specify at what stage a referral needs to be made to the General Practitioner about concerns around this. This will enable people to get the right kind of support to maintain their health. There must be sufficient 11/11/08 numbers of staff employed in the home at all times to make sure that people’s needs are fully met. Verbal references should be 11/11/08 follow-up in writing to confirm the validity of the person submitting the reference. This will help in making sure only suitable people are employed to work at the home. Requirement 2. YA19 12 3. YA33 18 4. YA34 19 Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 Good Practice Recommendations Care plans should be kept under regular review to reflect people’s current needs and any changing needs or risks to people. Further links should be established with external providers and the local community to develop the educational, employment and leisure opportunities for people living in the home. Arrangements should be put in place to repair the bedroom door, identified at the time of the visit so that it is able to fully close. This will help to reduce any safety risks to the person and will provide them with more privacy. YA12 YA13 3. YA42 Carlton Lodge DS0000006171.V371813.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Lodge DS0000006171.V371813.R02.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. 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