Inspection on 26/09/06 for Carlton Lodge

This inspection was carried out on 26th 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 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 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 08/07/2008.

CARE HOME ADULTS 18-65 Carlton Lodge 28 Carlton Street Normanton West Yorks WF6 2EH Lead Inspector Mr Tony Brindle Unannounced Inspection 26th September 2006 12:30 Carlton Lodge DS0000006171.V314196.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 Lodge DS0000006171.V314196.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 Lodge DS0000006171.V314196.R01.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 223652 care@hapton.freeserve.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.V314196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 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. People living at the home are all provided with bedrooms of their own room, which they can personalise. The staff help people to go out on trips, go to day services and develop daily living skills. People benefit from a visiting reflexologist and manicurist. The current fees for September 2006 range from £816 to £1050 per week per person. The service provider ensures that information about the service is available to prospective service users and the current people living at the home by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports, which are on offer at the home, and can be obtained through the registered manager. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection, a visit to the home took place. The inspector, Tony Brindle, visited the home unannounced from 1230hrs to 1600hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and the home’s policies were looked at, and so were the rooms. 4 people living at the home were spoken with. 6 members of staff were spoken with, along with the manager. The manager had been asked to complete a pre-inspection questionnaire, which was returned to the Commission. Comment cards were sent to all the people living at the home, their relatives, 3 visiting professionals and 2 GP’s. None were returned to the Commission. The Commission would like to thank everyone who took part in this inspection. What the service does well: People like living in the home. People’s needs are assessed before they move in. The staff receive good training. People receive suitable meals and are able to make choices about what they eat. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 6 People’s healthcare needs are looked after. The manager and staff make sure that people see the doctor or the nurse when they need to. People know how to complain. There are good systems in place to help people complain. People are offered choices about activities and keep in contact with their family and friends. People use the local facilities such as cafes and shops. People only move into the home once assurances have been given that their assessed needs can be appropriately met. People’s health, personal and social care needs are set out in an individual plan of care. Individuals are involved in decisions about their lives, and play a limited role in planning the care and support they receive (this is dependent upon their capabilities). Links with the community are good which supports people to use community facilities, engage within the community and take part in social and educational opportunities. The health and personal care that people receive is based on their individual needs. People feel their views are listened to and acted on. There are appropriate systems in place to protect people from abuse. Staff know what to do if alerted to suspected or alleged abuse. People live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. The current staffing numbers and skill mix of staff are appropriate to the assessed needs of the people, the size, layout and purpose of the home. The manager operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of people. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 7 The manager ensures that there is a good staff training and development programme and ensures staff fulfill the aims of the home and meet the changing needs of people. The management and administration of the home is based on openness and respect. Effective quality assurance systems have been developed by the Manager. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Carlton Lodge DS0000006171.V314196.R01.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.V314196.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The work of the staff and the systems operated at the home make sure that people only move into the home once assurances have been given that their assessed needs can be appropriately met. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The manager explained that admissions to the home are not made until a full needs assessment has been undertaken. The management team undertake all assessments. The records show that assessments are conducted with the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements the manager explained that he always insists on receiving a summary of the assessment and a copy of the care plan. This was evidenced within the service records. It is clear from discussions with the manager that admissions to the home would only take place if he felt confident that the staff had the skills, ability and competencies to meet the assessed needs of the prospective service user. The records show that the management team do consider prospective admissions together with other staff, and comments are listened to and fully debated, before agreement is given for the admission to take place. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 10 One staff member said that an individual member of staff is usually allocated to give new people information and to help them understand how the home is organised and run. This was evidenced within the service records. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 People’s health, personal and social care needs are set out in an individual plan of care. Individuals are involved in decisions about their lives, and play a limited role in planning the care and support they receive (this is dependent upon their capabilities). Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: It is clear from discussions with manager that the service has the strong belief that it is essential to involve people in the planning of care that affects their lifestyle and quality of life. Discussions with staff show that they understand the importance of people being supported to take control of their own lives, and staff said that people are encouraged and enabled them to exercise their rights and make their own decisions and choices. This belief is translated into the written care plans. The records show that the care plans are developed following person centred planning principles. One staff member said that they try and make the process of planning care interesting, using a variety of ways to enable people to make Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 12 a worthwhile contribution, by way of discussion and sometimes the use of picture cards. The records show that the plans are reviewed regularly involving the person living at the home, and, where agreed, their families. The manager said that the plans are updated and action taken to respond to any changes. The plans are written in such a way to focus on how people are to be encouraged to develop their skills and consider their future aspirations. Discussions with the staff show that they see the plans as a working tools. The records show that each care plan includes a comprehensive risk assessment. The management of risk takes into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, records are kept of why this decision was made and who was involved in the decision making process. This is kept under review. The manager confirmed that there are procedures in place to ensure that people are informed of their right to confidentiality, and understand when staff may share information to ensure individuals are safeguarded. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Links with the community are good which supports people to use community facilities, engage within the community and take part in social and educational opportunities. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The records show that people are supported to identify their own goals, where possible, and work to achieve them with the support of the staff. People living at the home confirmed that they have the opportunity to develop and maintain important personal and family relationships. Staff are aware of the needs to promote individual rights and choices, and the need to consider the protection of individuals, supporting people to make informed choices. This was evidenced within the service records, with particular reference to care plans and risk assessments. People living at the home confirmed that they are involved in different daytime activities of their own choice and according to their individual interests and Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 14 capability. The records show that people are supported to be involved in the planning of their daily life as far as possible. The manager explained that education and occupation opportunities are encouraged, supported and promoted, and that the abilities of each person are taken into consideration when looking into these types of activities. Some people access local colleges and day centres. People living at the home said that they can access and take part in activities within the local community, e.g. using public transport, and local leisure facilities. The manager explained that the principles of inclusion are very much at the fore of the work of the home, and this is evident through comments made by the staff and people living at the home, and through information contained within the home’s records. Staff members confirmed that where appropriate, people are involved in the domestic routines of the home, and if possible depending on people’s abilities, they take responsibility for or get involved in cleaning their own room, menu planning and cooking meals. The menu was seen to be varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 The health and personal care that people receive is based on their individual needs. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: Evidence was seen to show that any specialist health, nursing and dietary requirements are clearly recorded in each person’s plan; this gives a comprehensive overview of a person’s healthcare needs and the manager said that this acts as an indicator of change in health requirements. The Statement of Purpose details the specialist treatments; the home can deliver and refers to the skills and ability of the staff group. Discussions with the staff showed that they understand the key principles of giving personal support and are responsive to the varied and individual requirements of the people living at the home. The care plans support this by giving details to staff about delivering care personal care in a individual and flexible manner. The manager said that there is an emphasis on consistency. The staff said that where possible people are supported and helped to be Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 16 independent and responsible for their own personal hygiene and personal care. People living at the home confirmed this, and this was evidenced within the service records. The manager said that if people living at the home need personal aids and equipment then these would be accessed through the appropriate channels and agencies. The training records show that staff have access to training in health care matters and are encouraged and given time to attend seminars and lectures arranged by local health care organisations on specialist areas of work. Medication is checked and counted on a daily basis. There are information cards within each person’s file, which clearly states what medication they take, why they take it and what the side effects are. There is also a description of the tablets taken. A sample of the medication was checked which found that the manager and staff work to an efficient system which is supported by satisfactory procedures, procedures that are over and above the National Minimum Standards. The staff records show that staff have had appropriate training in medication administration. People living at the home who are assessed as being able to keep and take their own medication are encouraged to do so. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 People feel their views are listened to and acted on. There are appropriate systems in place to protect people from abuse. Staff know what to do if alerted to suspected or alleged abuse. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The records show that the service has a complaints procedure that is up to date, very clearly written, and is easy to understand. The manager confirmed that it can be made available on request in different formats (including other languages, large print, etc) to enable anyone associated with the service to complain or make suggestions for improvement. The manager confirmed that unless there were exceptional circumstances the service would always respond within the agreed timescale. The records show that to date, the service has not had any complaints. The policies and procedures regarding protection of individuals were found to be satisfactory. Discussion with the manager and staff showed that they are fully aware of when incidents need external input and who to refer incidents to. The records show that the manager regularly arranges the training of staff in the area of adult protection. No adult protection referrals have made since the last inspection. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 18 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 30 People live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: It is clear from touring the building that the home provides a physical environment that is appropriate to the current assessed needs of the people who live there. People living at the home and staff confirmed that the building is well maintained, pleasant and clean. People living at the home said that they are encouraged to personalise their bedrooms. The shared areas were seen to provide a choice of communal space with opportunities for people to meet relatives and friends in privacy of their own rooms. The records show that there is a satisfactory infection control policy with staff at the home willing to seek advice from external specialists. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 19 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 34 35 The current staffing numbers and skill mix of staff are appropriate to the assessed needs of the people living at the home, the size, layout and purpose of the home. The manager operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of people living at the home. The manager ensures that there is a good staff training and development programme and ensures staff fulfill the aims of the home and meet the changing needs of people living at the home. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The rotas show that the home is well staffed. The records show that staff members undertake external qualifications beyond the basic requirements. The manager encourages this and discussion with him indicated that he fully appreciates the need to have a skilled and well-trained workforce. Staff confirmed that they received job descriptions and specifications, which clearly define the roles and responsibilities of the staff. The records confirmed this. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 20 The staff training records show that the staff undertake relevant training that is targeted and focussed on improving outcomes for people living at the home. The service uses both internal and external providers to deliver training. The manager explained that training can be small scale and individualised if necessary in order to promote the delivery of person centred services. The records show that the service has a good recruitment procedure that clearly defines the process to be followed. The manager explained that staff meetings take place regularly. The records confirmed this. Supervision sessions are regular and staff say that they find them helpful, and that notes are taken of meetings and sessions. The records confirmed this. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 21 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 42 The management and administration of the home is based on openness and respect. Effective quality assurance systems have been developed by the Manager. Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. The staff said that they feel there is a strong culture of being open and transparent in all areas of running of the home. The service has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. The manager and staff make sure that so far as is reasonably practicable, the health, safety and welfare of people living at the home and staff is promoted, by way of appropriate written risk assessments and action to minimize risks. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 22 The fire safety system is tested and a record made. Staff explained that they take part in fire drills, and have received fire safety training, along with health and safety training. The records supported this. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice e.g. direct observation, supervision and team meetings. Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 23 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 X 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 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 4 X 3 X 3 X X 3 X Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations Carlton Lodge DS0000006171.V314196.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road 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 DS0000006171.V314196.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!