Inspection on 18/12/07 for Carlton Lodge Nursing and Residential Centre

This inspection was carried out on 18th December 2007.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Carlton Lodge Nursing and... 11/12/08

Carlton Lodge Nursing and... 11/07/07

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Carlton Lodge Nursing and Residential Centre 21 Victoria Parade Broadstairs Kent CT10 1QL Lead Inspector Debbie Calveley Key Unannounced Inspection 18th December 2007 09:00 X10015.doc Version 1.40 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 Nursing and Residential Centre DS0000069044.V354261.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 Older People. 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 Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Lodge Nursing and Residential Centre Address 21 Victoria Parade Broadstairs Kent CT10 1QL 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) 01843 862577 01843 603793 lane@bupa.com www.bupa.co.uk BUPA Care Homes (ANS) Ltd Deborah Jayne Lane Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (5) of places Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 41 beds in the home 37 are registered for the admission of nursing patients and 32 for residential clients. To admit 1 service user to the home whose date of birth is 18/10/23. Date of last inspection 11th July 2007 Brief Description of the Service: Carlton Lodge is a detached 4 storey premises, which was built in 1899 and is over 100 years old. The home is registered to provide nursing care and support for up to 41 older people over 65 years and 5 individuals with physical disabilities. From previous information received there are 18 single bedrooms and 6 doubles. Ten bedrooms have en-suite facilities of toilet and washbasin, two of which also have en-suite baths. The day space consists of two interconnecting lounges on the ground floor, a dining room and a large activity room in the basement. A shaft lift provides access to all levels. Each bedroom has a television point and a call alarm. Some bedrooms also have telephones. The Home is located near the town centre, on the seafront, overlooking a bandstand and the Victoria Gardens. It is within close proximity to the local shops and all public amenities. There is a small garden to the rear and small car park. Fees charged as from 1 April 2007 range from £425 to £700, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Carlton Lodge will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 6 hours on the 18 December 2007. There were twenty-six residents living in the home on the day, of which five were case tracked and spoken with. During the tour of the premises six other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Two members of care staff, activity person and the cook were spoken with in addition to discussion with the Manager. Telephone contact was made with visiting professionals following the visit and one relative was spoken with during the inspection visit. The information received verbally has been incorporated into this report. An Annual Quality Assurance Assessment was received from the Manager completed in full prior to this key inspection. Following the key inspection in July 2007, an Adult Protection investigation was conducted and admissions to the home suspended. The organisation produced action plans and improvement strategies to address the shortfalls and the suspension of admissions was lifted in October 2007. What the service does well: There is a comprehensive Statement of Purpose and Service Users Guide that give prospective residents the information required to enable them to make an informed choice about where they live. A welcome pack with a personalised letter of welcome is now given to all residents on admission. Residents confirmed that they were visited by the Manager prior to admission to the home and one stated they had been invited to visit the home to see if they liked it enough to live there. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 6 The menus evidence a well thought out balanced diet with a varied choice of food in line with resident’s preferences. Quality assurance systems are in place, which enables the service to monitor and improve their service. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard residents’ finances. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of suitably qualified staff working in the home. The atmosphere of the home is now pleasant with good interaction seen between residents and staff. The comments received from residents and families regarding the care received included: ‘Staff efficient and polite ’ ‘ there has to be a bit of give and take on both sides’ There is a robust recruitment process in place to protect the residents. Carlton Lodge provides a clean, safe and well-maintained environment, which is appreciated by the residents and their relatives. What has improved since the last inspection? There is a range of well-documented information about the home and the services it provides. Since the last inspection this documentation has been reviewed and updated. Since the last inspection a new care plan system has been introduced which includes a new pre-admission document. The health documentation of three new residents and those residents with pressure damage were viewed and were of an improved standard. The meals seen were attractively presented and the menus viewed indicated a well-balanced and nutritious diet. Residents confirmed that they are offered a choice of meals. There is a range of suitable adaptations and equipment to meet the needs of residents. All equipment in use was seen to be functioning appropriately. New sluicing facilities are now in place and operational. The home have implemented good infection control procedures to ensure that residents and staff are safeguarded. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 7 From direct observation and from viewing the staffing rota it was seen that there were suitably qualified, competent and experienced persons working at the care home to meet the health and welfare needs of the residents. The Organisation have provided appropriate support systems to the Registered Manager to enable her to actively promote the standard of care provided at the home. 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 Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission although people are not assured in writing that their needs will be met. EVIDENCE: There is a range of well-documented information about the home and the services it provides. Since the last inspection the documentation has been reviewed and updated. The home has a combined Statement of Purpose and Service Users Guide and a copy of this is available along with the last inspection report and a copy of the home’s terms and conditions of residency in the front entrance area. Each Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 10 resident is now presented with an individualised copy with a personalised letter of welcome to the home on arrival to the home. Relatives and relatives spoken to were clear on the service provided by the home and costs involved. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. There is a copy of the terms and conditions of residency included in the Service Users Guide. The registration certificate is clearly displayed and was found to be accurate. Since the last inspection in July 2007 a new care planning system has been introduced, which includes a new pre-admission document. The last three admissions to the home were identified and the records relating to the admission procedures followed were reviewed. This process confirmed that pre admission assessments are completed and provide an assessment of prospective residents care needs. These are completed by the Manager who confirmed that these are used to ensure new admissions to the home are appropriate and that the home have the staff, equipment and environment to meet their care needs. The documentation includes the times and dates of the assessment, who was involved and where it was held. It was discussed that the pre-admissions are quite brief and impersonal at the present time, which the Manager confirmed will improve as staff use the tool, the latest admission viewed was more informative and person centred than the first two. Prospective residents are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. It was however noted that the home does not confirm having regard to the assessment that the home can meet the assessed needs of the prospective resident. This was discussed with the Manager who was advised that this should be completed in writing in accordance with the required documentation. The Manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses and carers employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits to the home can be arranged. The Manager confirmed that selffunding residents are invited to a trial period to ensure suitability of the home; Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 11 this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Intermediate or rehabilitative care is not provided at Carlton Lodge. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provide a good framework for the delivery of care, which give clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed, however medication practices in the home do not protect the residents at this time. EVIDENCE: A new care planning system has been implemented since the last key inspection in July 2007 and this has required a great deal of work on the part of the senior staff in the home to input all the necessary information. Professionals reviewing the care documentation commented on its improvement and clarity. The inspection process however identified a small amount of shortfalls in the care documentation albeit that it is acknowledged that this system has only been operational for one month. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 13 Five individual plans of care were reviewed in depth as part of the inspection process and these identified that plans of care are written according to residents individual needs giving guidelines to care staff on how to deliver person centred care. As discussed there are some areas that still need to be improved and this is directed at outcomes and encouraging independence, e.g. promoting continence, communication and mobility. Risk assessments for health needs are included in the care planning format used by the home, and all risk assessments were found to be completed, and followed through with an appropriate plan of action when identified as required. Systems for assessing resident’s risk of developing pressure sores are in place and wound care documentation was accurate and up to date. All care files evidenced review and resident participation when able. It is acknowledged that a lot of hard work has been undertaken by the staff to improve the records and documentation and that training in care planning is on going. Staff receive a report on each resident daily and felt that their views were taken into account when planning resident’s care. The clinical room is also the staff office; it is keypad operated and kept closed when not in use. There is a small fridge and temperatures of the room and fridge are recorded daily. There are policies and procedures in place for staff to refer to regarding the safe administration, storage, disposal and recording of medication. The systems for recording and checking controlled drugs were found to be thorough. The practices for dispensing medication have been reviewed and now one trained nurse dispenses the medication for the whole home, whilst the other trained nurse takes on the running of the home, this ensures that the nurse dispensing the medication is not called away or disturbed. However the Medication Administration Charts were still found to have gaps, and no evidence of staff checking as to identifying if the medication had been administered, this included insulin and a controlled medication. Also staff are not signing medication changes, short term courses are not being signed off and dated and staff are not pre-ordering medication in time and thus recording medication out of stock for over 48 hours. Residents’ blood sugars are being recorded and whilst unstable blood sugars are identified and staff were verbally able to discuss the actions taken, there was no written evidence or links in the residents care plan that they were seeking advice from the diabetic nurse or G.P. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 14 These shortfalls were discussed and the Manager is to commence an internal medication audit on a regular basis to identify and address poor practice. Staff were seen to be respectful and considerate to all residents and visitors, whilst attending to their needs. Each of the residents was addressed by their preferred term and dressed appropriately in well-laundered clothing. Residents spoken with said they were ‘treated with respect and that staff were very kind’ ‘ nice girls, always kind and friendly’. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced by residents at this time matches their expectations, choice and preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: The activities provided in the home have been well received and enjoyed by residents that were spoken to. The monthly special events and weekly activity programme are displayed in the home and the activity person also visits each resident and gives them the weekly programme. There is evidence of one to one sessions with residents that are not able to join the activities. Records regarding activities are well kept, but it was discussed that care staff should also enter their interaction with residents. The programme evidenced visits by professional singers, P.A.T dog and for the Christmas season carol singers from the local Church and schools. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 16 Staff confirmed that the activities in the home have been a great benefit to residents and that celebrations are held regularly for special occasions including birthdays. The activity person is enthusiastic regarding his role and is committed to reviewing and seeking ways to develop the activities with the resident’s preferences. Discussions with residents confirmed that they joined in activities only if they chose to do so; some residents prefer their own company and often spent their time in their own rooms. Resident’s rooms were found to be individual and personalised and each resident has their preferred term of address recorded in their care documentation and this preference was respected. Residents were seen to have their choices respected throughout the day with decisions being responded to. The Manager confirmed that residents are asked their preferences regarding the gender of their carer, their daily routine, religious and cultural beliefs and food. This is to be regularly reviewed and incorporated in to their care plans. The activity programme evidences Holy Communion and it was confirmed that they will support residents if they wish to visit a local church. Visitors spoken to were all happy with the visiting arrangements and how staff who were said to be ‘very welcoming’ received them. The chef has recently left and the post has been filled with a starting date of January 2008, until then an agency cook is in post. The kitchen was well organised and clean; there was plenty of fresh fruit and vegetables seen. Breakfast and the mid day meal were observed and were seen to be better organised and well managed ensuring that those residents needing assistance were given time and able to have the assistance that they needed in an unrushed manner, staff were observed sitting with them at the tables. It was confirmed that residents had a choice at lunchtime, which included a vegetarian choice. Those residents saying they did not like the main choice were seen to have alternatives provided that they did want. The meals provided looked appetising and were served in a manner that ensured it looked attractive. Menus are used and circulated the day prior to the meals being provided but records are not kept on what food is eaten by each resident and it was discussed that this be commenced to ensure that appetite traits are identified Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 17 early. All feedback about the food was complimentary and comments included ‘good food’ ‘I have choices in the meals and the meals are good’. The dining area is situated on the first floor and is pleasant and well furnished with natural light. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is evidence of an improved complaint procedure that demonstrates a more thorough and robust investigation and includes an action plan. Staff are receiving training to protect residents from abuse. EVIDENCE: The organisational complaint policy and procedure is clear and uncomplicated and is displayed in the home and included in the Service Users Guide. Two residents spoken with said that if they were unhappy they would talk to the Manager or a member of staff, one visitor confirmed she would talk to the person in charge. The complaint book was viewed and evidenced that two complaints had been received since the last inspection and there was evidence of investigation, a recorded outcome and response to one of the complainants. All complainants need to receive a written response. The timescales of the complaint policy and procedure were adhered to. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 19 There have been no complaints received by the CSCI since the Adult Protection Investigation was completed in October 2007. A training matrix has been devised and evidenced that whilst not all staff have yet received training in Safeguarding Adults there is a rolling programme that will address this. The residents are protected by robust recruitment procedures and financial policies and procedures. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents and their families are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: A tour of the home confirmed that the home is generally well maintained and rooms are attractive with some being very personalised. Residents spoken to said that they liked their rooms, one saying that the home ‘felt like her home now’. Bedrooms are being updated and redecorated on a rolling programme of refurbishment; the newly decorated rooms are attractive and furnished with good quality furniture. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 21 The home do have bedrooms that are not in use due to stairs and they are difficult to access by residents and this is under review. The communal areas are attractive and allow for different uses ensuring residents have choice and how they spend their time. However the two lounge areas appear crowded, partly due to the positioning of chairs. The dining room is large and bright with clear views of the sea. There is also a large room on the lower floor, which is used for activities and this could be utilised more. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There are systems in place for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. The records in the home confirmed they were up to date. The tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. There are new sluices in place and this has improved the infection control procedures in the home. The laundry areas were found clean and safe and the home provides a good laundry service. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents, and on-going staff training will ensure staff are able to provide the support and care to meet the resident’s needs. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the Manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. The staffing levels need to be reviewed regularly against the needs of the residents in the home. Care staff spoken with said that the levels of staff on duty were sufficient to give the care required; they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff. A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. There was evidence of health Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 23 questionnaires, Criminal Records Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. The induction programme is now in place and has been introduced for all staff. Files seen confirmed this. The completed Annual Quality Assurance Assessment stated the home have a rolling programme of training for all staff throughout the year, to ensure that they have the necessary training updates and provide extra training that may be identified at supervision or performance review, without impacting on the service provided to the residents. All staff have or are currently undergoing mandatory training and this will be recorded in their file. This was confirmed by the Manager at the inspection visit. The training matrix is still a work in progress and is currently being updated. National Vocational Training has been difficult to set up due to a lack of assessors but is being introduced with staff commencing training in January 2008. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from an improved management approach and support systems have been introduced to ensure that the improvements made are maintained. The health, safety and welfare of residents and staff are generally well promoted and protected. EVIDENCE: The Registered Manager is a first level registered nurse and has been in post since September 2006, she is due to complete the Registered Managers Award in January 2008. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 25 The atmosphere in the home has improved considerably, the Manager was confident of the improvements in the home and was up to date with the needs of the residents and was able to locate all the documents required during the inspection. There are systems in place to monitor the quality in the home and include the use of questionnaires. The Manager confirmed that resident satisfaction questionnaires are sent out regularly, audited, reported on and responded to. It was recommended that the use of questionnaires is expanded to staff and visiting professionals. Regular staff meetings contribute towards the feedback of the home’s services; resident meetings have been cancelled as they were poorly attended by residents and their families. The Manager stated that the home operates an open door policy and the residents know that the staff will always listen. There are systems in place for the home to effectively manage the resident’s personal allowances, and records are kept. Staff supervision was discussed and regular staff supervision takes place. Staff spoken with confirmed that they receive supervision and that they find it helpful. At present not all staff have received the mandatory training in moving and handling, health and safety and fire safety. However, there is evidence of a rolling plan of training that will address this. The Manager confirmed that all staff are appropriately supervised until they have received the necessary training and induction. There are policies and procedures in place for promoting the health and safety of the residents and staff, these are reviewed regularly and updated when necessary. All the policies and procedure manuals are kept in the clinical room/office and are available to all staff, a system of ensuring staff have read and are aware of these manuals needs to be recommenced and discussed at staff meetings. The accident book was viewed and evidenced that an audit is performed monthly and action taken accordingly for those residents that are at risk from falls. First aid boxes are available but it was discussed that they should be easily accessible for staff to use in the event of an injury. Good practice was observed throughout the inspection in respect of promoting the safety and well being of the residents. Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 26 Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 3 3 3 2 3 Carlton Lodge Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1) Requirement That the registered person confirms in writing that having regard to the assessment made on any prospective service user that the home can meet those needs. That the registered person ensures that the care plans accurately reflect the needs of the service users in respect of their health, social and behavioural needs. Timescale for action 01/02/08 2. OP7 15(2) 01/02/08 3. OP8 12(1)(a) 4. OP9 13(2) That service users and/or their representatives are consulted regarding the formation of the care plans. 01/02/08 That the registered person ensures that the care home is conducted so as (a) to promote and make proper provision for the health and welfare of service users, this specifically refers to diabetes, promotion of continence. That the registered person 01/02/08 ensures that there is a policy and staff adhere to the procedures for the receipt, recording, DS0000069044.V354261.R01.S.doc Version 5.2 Page 29 Carlton Lodge Nursing and Residential Centre 5. OP16 22 6. OP18 13 (3) (6) (7) (8) 18(1) 7. OP30 storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework (Timescale of 31/07/07 not met) That the registered person ensures that all complaints are appropriately recorded together with information in relation to the action taken and the outcome. (Timescale of 31/07/07 not met) That the registered person ensures that all staff receive training in safeguarding vulnerable adults procedures. That the registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. (Timescale of 31/07/07 not met) 01/02/08 01/02/08 01/02/08 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 Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Nursing and Residential Centre DS0000069044.V354261.R01.S.doc Version 5.2 Page 31 - 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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