Inspection on 17/01/06 for Carlton Manor Care Home

This inspection was carried out on 17th January 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 Manor Care Home 25/02/09

Carlton Manor Care Home 22/02/07

Carlton Manor Care Home 12/09/05

Carlton Manor Care Home 29/09/04

Carlton Manor Care Home 27/04/04

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Snydale Care Home

Larchfield Manor

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The Grove Waltham

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Carentan House

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Carlton Manor Care Home Parkfield House 23 Parkfield Road Bradford West Yorkshire BD8 7AB Lead Inspector Barbara Grell Unannounced Inspection 17th January 2006 09:30 X10029.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 Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 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 and 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 Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Carlton Manor Care Home Address Parkfield House 23 Parkfield Road Bradford West Yorkshire BD8 7AB 01274 544374 01274 491985 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) Carlton Nursing Homes Ltd Michelle Ann Holstead Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (11), Physical disability of places over 65 years of age (24) Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12/09/05 Brief Description of the Service: Carlton Manor is a period property that was used as a private residence and later as a convent prior to being used as a care home. The house has many of the original features with much panelling and ceiling ornamentation still in place. The house is situated in it’s own secluded grounds and is located for easy access form central Bradford. There are regular bus services and there is ample parking within the grounds. Care is provided for up to thirty-three service users with a physical disability. Up to eleven service users are younger adults other’s are over 65. Bedrooms are situated on the ground or first floor and there are single and double bedrooms the majority have en-suite facilities. A passenger lift and other mobility equipment are provided for. Ramped access is available to the rear entrance. There is a choice of three communal lounges and a large dining room. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced on 17/01/06 between 9:00 and 14:45. In line with CSCI policy a number of core standards were inspected. There were no outstanding items from the previous report. Reports and information on this and other social care services can be accessed on www.csci.org.uk. The following methods were used to judge the standard of care and services. The registered manager and seven members of staff were able to make comment of about the care and services provided at the home. Documentation including four case records and two recruitment, supervision and training records were inspected. Eleven service users and one visitor were able to comment on their experiences. Survey materials are available for service users and visitors to make comments to CSCI at all times. Part of the building was looked at and maintenance personnel were able to comment on issues of safety and upkeep. What the service does well: What has improved since the last inspection? What they could do better: Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 6 There are no recommendations or requirements following this inspection. 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 Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 OP 4 YA Prospective service users are able to visit the home and test the service and facilities. EVIDENCE: Several service users were able to make comment about their admission experiences. Individuals are invited to visit the home and spend as much time ‘testing it’ as they need and wish to. Opportunity is ensured for prospective service users to move in on a short-term basis, return home and decide whether to move in long term. This benefits the service users and ensures that informed choices could be made. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 OP, 6, 9, 16, 18, 19 & 20 YA Care and services are tailored to the needs, wishes and skill level of the service users. Service users are treated with respect and privacy is maintained. EVIDENCE: Four case records were inspected including the activities file. The assessments and care plans are clearly recorded and give good detail of what staff have to do to meet the needs of the service users. Care plans are individualised and provide details of preferences and expectations. Service users have input into the care plan and clearly contribute. Staff ensure that the service users wishes are ascertained and included. Interaction showed that staff and service users Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 10 have good relationships and individuals are clearly able to make choices. Service users sign the care plan when able to give consent. The staff ensure that there is ongoing review of the service users changing needs and records are up to date and changes are clearly recorded. Again the service users consent is sought. Risk assessments are undertaken to judge the risk of pressure sores, falls, poor nutrition and other risks such as administering medicines and going out independently. The risk assessments inform the care plan. The activities file includes a history giving very good detail about the individual’s lifestyle, education, work history, hobbies and family and cultural preferences. This again underpins the care plan the type of activities provided. Registered nurses employed by the home provide nursing treatments. The nurses are able to get help and advice from NHS professionals and specialists. Individuals are regularly monitored by a dentist and optician. Two staff are trained to cut toenails. Care plans include details of the service users nursing needs. There are comprehensive policies in place with regard to the administration of medicines. Nurses are trained to administer medicines and training is provided periodically in this respect. The medication records are accurate and up-todate. There is appropriate storage and medicines no longer needed are appropriately destroyed. Service users are able to administer all or part of their medication within a risk management system. One example was seen in this respect. Treatments and personal care are provided in private. Service users feel treated with respect and reported to have a good rapport with a consistent, capable and professional staff team. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 OP, 7 & 17 YA Service users feel that they control their own routine and exercise choice in all parts of their life. The food provided is enjoyed and provides for ample choices at each meal. EVIDENCE: The service users were able to report that they are able to make appropriate choices about their lifestyle, activities and the way care is provided. Staff as well as the manager spends time in one-to-one and group conversation and discussions. Service users benefit from staff that listen to their wishes and that are able to incorporate individual preferences into the support they give. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 12 The service users are served meals in their own room or the communal dining room and this is their choice. At breakfast a cooked or continental breakfast is chosen. Dinner is a two course hot meal and the main meal of the day. Tea is somewhat lighter and choices are given at each meal. Special diets are catered for. By liquidising individual food portions individual tastes and colours are maintained. The inspector joined service users for lunch in the dining room. The meal was well prepared and presented. Service users had a chat and sing-along erupted to music at times. The atmosphere was happy and the meal much enjoyed. The meal was well-conducted and service users given enough time to eat. The chef tours the dining room and engages with service users regularly. Meals are varied and nutritious. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 OP, 22 &23 YA Complaints and adult protection policies ensure that any concerns are investigated and appropriately reported. EVIDENCE: A complaint procedure is in place and part of the service user guide. Many service users knew how to make a complaint. One complaint was received, investigated and responded to. The manager said that she takes any complaint and concern seriously. She ensures that service users have ample opportunity to speak to her. Good communication is ensured. Staff are provided with training to ensure that is a good level of awareness in respect of protecting vulnerable adults and reporting any concerns. This training is provided internally. Adult protection procedures and local Adult Protection contacts are available. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 OP, 24 & 30 YA The building benefits from ongoing maintenance and improvement. Infection control and hygiene practices are of a good standard. EVIDENCE: The operations manager was able to discuss ongoing improvements and plans. There is ongoing maintenance and ongoing plans for the replacement and upgrade of furniture and fittings. The maintenance man undertakes ongoing repairs as well as gardening. Service users can help if they are able and want to providing further activities for some individuals. The house has many period Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 15 features and large grounds that are enjoyed and appreciated by the people who live and work in the home. Staff receive training in the areas of food hygiene and infection control. Cleaning schedules ensure that all areas are regularly cleaned and sanitised. The laundry is well-organised and good hygiene practices prevail. Contracts are available for the removal of clinical waste from the home. Anti-bacterial soap and paper towels are available in appropriate areas for hand washing. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 OP, 31, 32, 34 & 35 YA A stable, competent and well-trained staff team ensures that service users received a good standard of care and services. EVIDENCE: Just over 50 of staff are qualified to NVQ level 2 and some of those staff are now undertaking NVQ level 3. Most of those staff who have not yet completed the NVQ level 2 are registered with a centre. Registered nurses are enabled to attend updates and appropriate training at regular intervals. Staff said they are well supported and provided with regular training opportunities. Manual handling, health and safety, fire, COSHH, infection control, first aid and other more specialised are included in the training program. New staff are provided with induction training and a programme of shadowing longstanding staff during the initial period of employment. Two recruitment files were inspected. All required documents were available. A record is kept of the date of any POVA and CRB checks and when details Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 17 were returned. References are taken up in writing. For foreign workers appropriate home office documents are held to show their status. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 OP, 36, 37 YA The manager is competent and qualified. Staff benefit from a good system of supervision. EVIDENCE: Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 19 The registered manager is a qualified and registered nurse. She has recently successfully completed her NVQ level 4 in management. The manager has a service user centred attitude and it was very clear in her interactions with individuals that she values their opinions. The staff are appropriately supervised by senior staff. Records are kept and a number inspected. The record showed that areas of conduct and personal development are discussed including training plans. Staff said that they are well supported by the manager. Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 20 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 X 2 X 3 X 4 3 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 X 34 X 35 X 36 3 37 X 38 X Carlton Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 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. 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 Manor Care Home DS0000033997.V277136.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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