Inspection on 18/05/05 for Carlton Lodge

This inspection was carried out on 18th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Carlton Lodge 18/08/09

Carlton Lodge 11/09/08

Carlton Lodge 12/09/07

Carlton Lodge 26/09/06

Carlton Lodge 12/01/06

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 08/07/2008.

CARE HOME ADULTS 18-65 Carlton Lodge 28 Carlton Street Normanton West Yorkshire WF6 2EH Lead Inspector Tony Brindle Unannounced 18 May 2005 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 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 Stationary 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 J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Carton Lodge Address 28 Carlton Street Normanton WF6 2EH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 223652 01924 223652 Hapton Care Homes Mr John Mcintosh YA 9 Category(ies) of LD 9 registration, with number of places Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection October 2004 Brief Description of the Service: Carlton Lodge provides personal care for nine 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. Service users are all provided with bedrooms of their own which they can personalized. The staff help service users to go out on trips, go to day services and develop daily living skills. Service users benefit from a visiting reflexologist and manicurist. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced 4½ hour inspection began just after breakfast and ended just after lunch. Eight service users, the manager and seven members of staff were spoken with. This was a positive and enjoyable inspection. The inspector would like to take the opportunity to thank the service users, the manager and support workers for their hospitality and patient cooperation throughout the inspection. During the inspection, the following documents were inspected: 2 care plans, the daily records, health and safety records, the complaints log, stakeholder satisfaction report, training records and two personnel records. A staff member briefly showed the inspector around the home. In the 7 months since the last unannounced inspection of Carlton Lodge took place, there have been no additional or complaints visit to the home. There have been no changes to the people who are registered with CSCI to manage or run Carlton Lodge. What the service does well: What has improved since the last inspection? The staff have put a lot of effort in to make sure that service users take part in activities and interests that are positive and worthwhile. These activities are linked to the needs, likes and dislikes of individual service users, many centering on developing self help and daily living skills. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 6 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. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 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 standard(s) 2 Good assessment procedures make sure that new service user’s individual aspirations and needs are assessed, and that they an be met, before a place is offered. EVIDENCE: The admission procedure operated by the home helps to guide staff on the actions they are to take to ensure that the needs of new service users are assessed effectively. Admission to the home follows a full assessment of need by a competent person within the organisation. A new service user, who had lived at Carlton Lodge for about 5 months said that the staff had spoken to him about his likes and dislikes when he had come to visit the home before moving in. The individual records for another service user showed that a full assessment had taken place, and that the supported given by the staff was based on this assessment. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 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 standard(s) 6,7and 9 The systems and procedures operated by the home, and the work of the staff ensure that service users assessed and changing needs and personal goals are reflected within an individual plan. Service users are assisted to make decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: Service user plans contain detailed information about support and healthcare needs. The plans have a straightforward approach, concentrating on aspects of daily living, providing a holistic overview of the service user and the support they require in order to move towards greater independence. Restrictions are only placed on the service users following an appropriate risk assessment. Service users spoken with said that their key workers usually put together the care plans after talking to them about their needs. Discussion with the staff showed that they have a good understanding of the support and care needs of the service users. Staff explained that service users are enabled to take risks based on shared information and a relevant risk assessment. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 10 One service user explained that he has had had a talk with the staff about using the stairs, which he now doesn’t use due to their use being too dangerous. He said that he doesn’t need to go upstairs because his bedroom is on the ground floor. He said he likes to use the shower which is very near to his bedroom. This service user’s file was seen to contain the risk assessment he spoke about. The home has an appropriate procedure should service users have an unplanned absence. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 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 standard(s) 12,13,15,16 and 17 The staff understand that lifestyle goals and interests will naturally vary according to the person’s age, culture, experience and interest. Opportunities for personal development and independent living are created, and service users access community facilities and leisure activities. It is clear that the staff play a key role in supporting service users to live fulfilling lives outside as well as within the home, and this should continue. EVIDENCE: Some service users said that they spend time outside of the home including visits to local shops, training centres and other organised activities. During the inspection, a service user returned back from a visit to the doctor, one visited the local shop to buy a newspaper, and others were supported to attend a day service. They explained that they go on trips on a regular basis, visit their families and use many of the local facilities such as shops, supermarkets and entertainment centres. One service user said he could go into the garden if he wants and pointed this area of the home out. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 12 The staff were seen to respect service users’ individuality, dignity and privacy both by appropriate form of address and by discreetly supporting individuals with personal care. The staff said that individual personal, cultural/religious and food preferences and requirements can be and will be observed. One service user said that the staff are good at cooking and try and make the things he likes and the things he asks for. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 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 standard(s) 18, 19 and 20 The systems and procedures operated by the home, and the work of the staff ensure that the personal and healthcare needs of the service users are identified and met. EVIDENCE: It is clear that the staff recognize that service users have the right to good quality physical and emotional health wherever they are living. The service users are supported to manage their own healthcare as far as is possible and to access NHS community facilities. Any specialist health, nursing and dietary requirements were seen in the service user’s wide-ranging individual plans. Staff explained that they support service users to manage their own medication following a risk assessment. The service user’s individual plans detail key aspects of how an individual seeks to be supported. One service user spoke about the fact that he doesn’t like to use the bath, and prefers using the shower. This aspect of his care and support was clearly written into his care plan. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 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 standard(s) 22 and 23 The systems and procedures operated by the home, and the work of the staff ensure that service users feel their views are listened to and acted on. There are systems and procedures in place to protect the service users from abuse and neglect. EVIDENCE: Policies and procedures for dealing with suspicion or evidence of abuse are in place. Complainants are informed that they may make complaints directly to the CSCI. One service user said that he could approach his key worker or any member of staff and raise any problems he had. The records show that a service user recently raised an issue about the support he had received, saying that improper sexual contact had been made by a staff member. The manager looked into this issue, and passed it onto the local authority. A meeting was held with the manager, the staff and the service user’s social worker, and the individual’s care plan records show that it was dealt with properly. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 15 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 standard(s) 24 and 30 The systems and procedures operated by the home, and the work of the staff ensure that the service users live in a homely, comfortable and clean environment. EVIDENCE: Staff members said that respect for service users’ privacy is really important, including the freedom to have their own space, receive guests and take part in activities they enjoy. This is informed via appropriate risk assessments. The staff were observed to respect the privacy and independence of the service users, which is limited as necessary for their safety or protection as specified in individual service user plans following an appropriate assessment. The facilities within the home are as home-like as possible while being fit for the purpose of the home and for the people who live there. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The systems and procedures, and actions of the staff ensure that service users are supported and protected by the home’s recruitment policy and practices. Service users benefit from well supported and supervised staff. The policy documents concerning the induction and probation of new staff should be updated to say how induction and probation is carried out at Carlton Lodge, and the reasons why. EVIDENCE: Two service users said that the staff are friendly and easy to talk to. One staff member said that she had received a lot of good training since she started work at Carlton Lodge about nine months ago. She also said that she has a lot more training lined up which is linked to support needs of the service users. The rotas show that there is a continuity of staff support, allowing service users to get to know people, develop good relationships with key-workers and take part in activities both inside and outside of the home. One staff member explained that she is aware of the likes and dislikes of the service users and feels that this is important when working with people. The personnel files show that the company undertakes satisfactory and appropriate recruitment checks, identifies training and development and provides appropriate supervision and support. New staff complete induction training, which is signed off by the home’s management team. One staff member explained that new starters on probation are shadowed by an Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 17 experienced staff member, and do not escort service users outside of the home unless accompanied. There was no written policy relating to this. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The systems and procedures, and the work of the staff team ensures that the views of service users are sought and acted upon in relation to the services they receive. The views of external stakeholders indicate a high level of satisfaction with the services provided at Carlton Lodge. The health and welfare of the service users and staff is protected by the safety systems operated by the home. EVIDENCE: The deputy manager was able to demonstrate that the home routinely seeks the opinions of the service users through regular talks and care planning updates. The unannounced monthly management visit looks at different aspects of the home’s provision e.g. service user views, environment, care plans. The deputy manager explained that company’s quality assurance and quality monitoring system seeks the views of other stakeholders such as GP’s, Nurses and Social Workers. The records of this show a high degree of stakeholder satisfaction in relation to the services provided at Carlton Lodge. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 19 The fire safety records were found to be satisfactory, showing the alarms are tested every week, that staff receive fire safety training and that service users and staff practice the fire drill. The portable appliance testing records show that appliances are tested for faults, which are corrected if identified. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 20 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carlton Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 21 no 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 Regulation Requirement none identified during this inspection Timescale for action 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 YA35 Good Practice Recommendations The registered manager should ensure that the induction and probation programmes run by the company are clearly written up so that they reflect the amendments to the Care Homes Regulations regarding induction and supervision of new starters, for the protection of service users. Carlton Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Brighouse HD6 4AB 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 Lodge J01J51_s6171_carlton lodge_v228107_180505.doc Version 1.30 Page 23 - 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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