Inspection on 07/07/06 for Carlton Mansions

This inspection was carried out on 7th July 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 Mansions 10/10/07

Carlton Mansions 21/02/06

Carlton Mansions 31/08/05

Carlton Mansions 24/02/05

Carlton Mansions 28/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Carlton Mansions 8 Apsley Road Clifton Bristol BS8 2SP Lead Inspector Grace Agu Key Unannounced Inspection 7th July 2006 09:15 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 Mansions DS0000026500.V301684.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 Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Mansions Address 8 Apsley Road Clifton Bristol BS8 2SP 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) 0117 9734394 0117 9238603 Acegold Limited (a wholly owned subsidiary of Four Seasons Health Care Ltd) Ms Sugandhva Jadeja Care Home 26 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (24) of places Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 named people who have dementia. Certificate will revert to 26 OP when persons leave. 21st February 2006 Date of last inspection Brief Description of the Service: Carlton Mansions is one of a group of residential care homes owned and operated by Four Seasons Health Care. The Home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for 26 people aged 65 years and over. Within the registration the home is registered to provide care for two named persons with a dementia. Carlton Mansions is located in a residential suburb of the city of Bristol. Local shops and amenities are located nearby. The home is a large Victorian property, and accommodation is arranged over four floors - a passenger lift enabling access. Individual rooms are comfortable, well maintained and personalised by the residents. The communal space consists of two lounges, a dining area and a conservatory overlooking the courtyard garden to the rear of the property. The current weekly fees are from £339 - £610 per week. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over eight hours and was undertaken to review the care practice to ensure that it is in line with the legislation and that best practice is being followed at the Home. This inspection also reviewed the requirements made at the last inspection to ensure that they have been met. The Home had made tremendous efforts to ensure that nine out of the ten requirements made were met. The outstanding requirement was in relation to providing staff with storage facilities. The manager stated that this would be included in the upcoming refurbishment plan of the building in October 2006. The requirement remains in place Residents looked well cared for and were noted interacting with staff in an informal and friendly manner. A tour of the building was undertaken; seven residents and three staff members and one relative were spoken with. A number of records were reviewed. What the service does well: Generally the Home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the Home was noted to be relaxed. Residents looked well cared for and staff were noted interacting with residents in an informal and personalised manner. At a discussion, the Manager stated that the Home continues to maintain high standards of care through regular care review. The relationship between staff and residents remain informal and cordial including the relatives. Residents and relative’s views are respected to reflect the home’s principles of inclusiveness. The home continues to provide good training for its staff both internally and externally to ensure that the needs of the residents are met. One staff member spoken with stated that there is good team building at the Home; this made a great impact in the care of the residents. Residents enjoy good nutritious food; this had contributed to their feeling of wellness. This was evident on the day. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 6 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 Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 7 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 Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The process of admission of prospective residents is comprehensive, detailed and well planned to enable the residents to make a choice of moving to the home EVIDENCE: The residents care files reviewed contained detailed assessment of physical, emotional and social needs before admission to the home. Residents spoken with made positive comments about the home and staff. One example noted on the comment card included “ I visited first and stayed for respite and my son recommended it. Then I decided to move from London with my wife because I liked the home very much”. One resident spoken with on the day of inspection stated “ I came to look round with my cousin and saw this room and liked it. I like it here staff are Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 9 very good and kind to us.” Another resident spoken with stated that they signed a contract at the home. It was agreed that the home provide prospective residents with a written confirmation that their needs will be met in respect of health and welfare after assessment. Staff spoken with demonstrated understanding of the needs of the resident. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers care and support to residents throughout their lives and towards the end, it also protects the residents by reviewing their health needs and there is appropriate drug administration. EVIDENCE: Four care files, including that for the individual whose relative was not satisfied with some aspects of the care provided, were reviewed. There was evidence of pre assessment before the residents were admitted to the home. The care files seen contained individualised care plans in relation to each assessed need and gave clear direction to staff to enable them to deliver appropriate care to the residents. Staff spoken with stated that they have access to the care files. These care files were noted to have been reviewed monthly and when needs change. In addition, there was a comprehensive and detailed care plan for a specific need of a resident with challenging needs and regularly reviewed risk assessment to ensure that these need are adequately met. Entries in the daily Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 11 progress note showed that care provision was being followed as written in the care plan. However, it was noted that there was no care plan in regard to one identified need relating to personal care condition. This individual was met relaxing in the lounge with other residents and stated, “ I am very happy here. Furthermore, it was noted whilst reviewing the care files that two residents’ risk assessments were last reviewed on 21/5/ 05 and 11/04/05, a manual handling profile had no date and there was no evidence of when it was last reviewed. These concerns were raised with the manager and a requirement has been made to remedy this situation. In regard to how residents perceive their care at the home, one resident stated, “ I am happy here, staff look after me well, I have a medical condition and is being managed well. I get up when I like and I go to bed when I like.” Another resident stated, “staff are very kind, I look forward to having my bath.” One resident stated staff “respect me and always made sure that the door is closed when I am bathing or using the toilet”. One resident stated “I signed my care plan.” Staff were noted knocking on the doors before going in to the residents rooms to assist them with personal care. The care files viewed had evidence of visits from the health professionals to include General Practitioners (GP) Chiropodists, Opticians and Dentists. Medication administration was reviewed and it was pleasing to note that the requirement made in relation to ensuring that all medication hand written on the Medication Administration Record Sheet (MARS) are signed and dated and that all medication are correctly labelled at the last inspection had been fully met. It was also noted at this inspection that the medicine policy was in place, there was evidence of receipt and disposal of medication, Controlled drugs were properly recorded and signed by two trained staff members and balance was correct. Staff spoken with were aware of measures to be taken if a resident became terminally ill and in the event of death. Staff also demonstrated awareness of the importance of ensuring that information about residents is kept confidential Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to maintain links with their families, they are also provided nutritious meals and meaningful activities EVIDENCE: Care plans reviewed contained a social assessment form which is completed by the resident or their representative on admission to enable the home to plan a suitable activity based on the details given. Whilst the home is making efforts to recruit an activities person, the manager stated that staff are allocated to organise activities for the residents on a daily basis. Records of the residents who participated in activities were noted in the activities book to include residents that declined and reason for decline. One resident spoken with stated I do not like to take part in activities, I am content in my room, I do a lot of reading”. Weekly activities displayed on the residents’ notice board included Board Games (Monday) Chair exercise (Tuesday), Cookery (Wednesday), Craft Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 13 (Thursday), Bingo, Sherry, Games (Friday). Photographs of a recent summer fete (26/06/06) were seen displayed at the reception. The manager stated that a leaflet of all planned activities is sent to the relatives and friends for their dairies and such planned activities is the Barbecue on 5/08/06, a trip to Chew Valley Lake on 19/07/06, and trip to the Bristol Zoo at a later date. The home is currently exploring ways of finding a place for residents who want to play “Bridge” Residents spoken with stated that the home actively supports them to maintain contact with families, friends and representatives and that visiting time is not restricted. One resident told the inspector that their family visit regularly. “The Vicar or a lay person from the church comes to see us because I find it difficult to get around”. Another resident stated, “Our friends and relatives come to see us”. It was suggested that the home contact one resident’s country cultural organisation after consultation with the resident and family. This is to offer the resident the opportunity to maintain links with their background. Other comments made by residents include “My cousin lives in Portishead and had visited once. My daughter comes to seem me; my son came yesterday, bought me a wheelchair and took me out. My grandson came to see me the other day” The menu on the day was displayed on the notice board at the reception. The lunch menu on the day included Poached fish, steamed peas and slice of lemon with Scampi as an alternative. It was also noted that the residents were offered a glass of wine each with their meal. Residents spoken with after lunch stated that they enjoyed their meal. One resident stated, “Food is excellent, I can’t eat it all.” Staff were noted interacting with residents at mealtime and residents who needed assistance were helped in a sensitive and dignified manner. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure the protection of residents from harm and abuse EVIDENCE: The Commission for Social Care inspection received the copy of response to the letter to a relative by the Social Services in relation to concerns raised by the relative about unsatisfactory personal care of an individual at the home. The relative was also concerned about the poor cleanliness of the room on the day of the relatives visit. The Social Services requested that the home investigate the allegation and inform them of the outcome. At a discussion with the manager, it was agreed that a copy of the outcome of the investigation be forwarded to the Commission. This complaint was recorded in the Complaint book on the day of inspection. The individual’s care file was reviewed in relation to personal care needs and the findings had been previously discussed in Standard 8. The Home has appropriate and robust procedures in place for management of complaints. The complaints procedure was noted displayed in the hallway at the entrance. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 15 This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. Residents spoken with and responses noted on the comment card evidenced that residents are aware of whom to complain to. One resident stated, “I have no reason to complain”. One resident stated that they are aware of their rights and were enabled to vote using the postal voting system. Staff are aware of the Whistle Blowing policy and would report any bad practices to the Manager without fear of reprisal. There is evidence of staff training in relation to Protection of Vulnerable Adults from Abuse. There is a copy of the Bristol City Council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidents of abuse occur. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents enjoy a suitable, safe environment, however, the home fails to adequately maintain some areas of the building. EVIDENCE: Whilst touring the building the home was found to be generally clean, warm, well lit and free from offensive odour and suitable for its stated purpose. The bedroom of the resident whose relative raised concern in relation to cleanliness was noted to be clean and tidy on the day of inspection. The home is currently carrying out an investigation and it is expected that a copy of the outcome would be sent to the Commission for Social Care Inspection. Residents sitting in the lounges, looked relaxed, well cared for and enjoying each other’s company. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 17 Some residents spoken with stated that they felt safe at the home. At the inspection a requirement was made for heavily stained carpets in the hall way of the new extension to be deep cleaned or replaced. It was also noted at this inspection that carpets in different areas of the home were heavily stained. The manager stated that the carpets have been included in the planned refurbishment-taking place in October 2006. The laundry was found clean and tidy, there were adequate laundry facilities and the laundry staff met on duty stated that resident’s clothes are placed in individual boxes and are put away by the laundry person. However, it was noted that the wall next to the laundry area had flaking paint leaving the area exposed. This is hazardous to the resident’s staff and visitors and must be repaired. The manager stated that this is also included in the refurbishment already planned. This will be reviewed at the next inspection. The last inspection requirement in relation to providing appropriate storage for staff was reviewed. This requirement had not been met, the manager stated that this is being included in the refurbishment plan for October 2006. It was noted that the same residents bathroom used by staff to store their personal effects was noted locked and residents were denied access to the use of this facility. The manager stated at a discussion that the bathroom was locked due to improper use of the facility by a resident on that floor. A requirement was made for the home to ensure that residents are not restricted from the facilities provided for them. Soiled clothing is washed separately and staff inform the laundry of any infection at the home. Staff were noted wearing aprons and gloves and washing their hands after attending to the residents. This demonstrated that infection control and principles of hygiene is well maintained at the home. The maintenance book was up to date clearly stating jobs/tasks to be carried out, date completed and any relevant comment in relation to outstanding jobs Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing level at the home is sufficient to meet the needs of the residents. Staff receive training and are competent, however, training on challenging behaviour has not been provided to protect the residents. EVIDENCE: Evidence from staff rota and discussion with the manager showed that the home has a sufficient staffing level to meet the needs of the residents. It was pleasing to note that the requirement made at the last inspection in regard to ensuring that adequate numbers of domestic staff were on duty has been met. Residents spoken with stated that staff are kind, attended them when they rang the bell and treated them with respect. The home operates a key working system to enhance the resident/staff relationships. Staff have attended training to include Dementia Awareness, however it was disappointing to note that staff have not received training on challenging behaviour in order to fully meet the requirement met at the last inspection. The manager stated that the home plans to provide staff with this training within the year. The requirement remains. Other training attended includes Protection of Vulnerable Adults from Abuse, Basic Food Hygiene, First Aid and Control of Substances Hazardous to Health. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 19 It was also noted that some staff members have achieved National Vocational Qualification (NVQ) at level 2 and 3. One staff member spoken with confirmed that they were currently undertaking NVQ at level 3. The recruitment policy and procedure is robust and documentation in relation to recently appointed staff was satisfactory. It was pleasing to note that the requirements made at the last inspection in relation to fire training and undertaking a generic risk assessment of the home including the dining area have been met Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 33,35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership and management its practises offer protection to the health and safety of residents. EVIDENCE: The atmosphere at the Home on the day of inspection was positive and welcoming. Staff were noted interacting with residents in an informal and friendly manner. Staff spoken with stated that staff work as a team and that the Manager has good leadership qualities. These have enabled staff to provide quality care and to support the residents. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 21 Residents spoken with made positive comment about the Manager, Ms Sungandhva Jadeja who they fondly call “Shobi” One resident stated that Shobi is kind, “she comes to see us. Nothing is too hard for her. I would go complain to the manager if I have any concerns.” One comment card received from a health professional states “ I regard Carlton Mansions as a very well run home possibly the best in this area. They have an experienced long serving matron, capable and good relationships with residents”. A comment card from a relative states” Absolutely lovely home, I am happy with the care and love my father receives. The staff are always kind and caring to all residents” The manager had recently received a long service award from the organisation in recognition of her dedication and hard work. The manager stated that regular support and supervision from the Regional Manager has enabled her to deliver a quality service and efficient leadership to the home. At a discussion, the Manager stated that she had recently completed Manual Handling Training for Trainers Course to enable her to train and update staff routinely and when necessary. The manager also stated that she recently attended First Aid training update with the Deputy Manager to ensure that residents, staff members and visitors are protected in medical emergencies Staff supervision was reviewed. Evidence from the records viewed showed that staff have received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the exercise. It afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to residents’ care Health and Safety records showed that the home had undertaken generic risk assessments of vulnerable areas of the home including the dining area as required at the last inspection. Other health and safety records are up to date. Accidents were noted to be properly recorded and reviewed as required. The fire log-book was noted to be up to date and evidence from records and confirmation from staff showed that staff have attended fire drills. Quality assurance for the Home was reviewed. The Manager stated that the home audits it quality of service using different tools. These include leaflets for feedback from health professionals, relatives and residents; one to one discussions with residents following any concerns raised are resolved as soon as possible; Medication audit; Residents’ money audit; Risk assessment of individual residents and general risk assessment of the home; staff supervision; care plan reviews monthly and when required; monthly health and safety checks; discussions at residents’ and staff meetings. Carlton Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 22 The most recent resident’s meeting was on 23/3/06, issues discussed include Food, Activities, Day Care, Night Care and general matters. The home has policies and procedures to include Protection of Vulnerable Adults from Abuse, Medication, Whistle Blowing, Manual Handling and Infection Control. These have recently been updated. Residents’ monies checked evidenced that the record is up to date. Other residents’ documented information was noted to be securely locked away. Carlton Mansions DS0000026500.V301684.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 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 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Carlton Mansions DS0000026500.V301684.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. 1 2 Standard OP30 OP21 Regulation 18 13 (4)(a) Requirement Ensure that staff receive training in dealing with challenging behaviour. Ensure that residents have access to bathroom facilities after appropriate risk assessment. Confirm in writing to prospective residents of the home’s ability to meet their needs. Ensure that residents risk assessment and manual handling profiles are reviewed and updated respectively. Provide a care plan for specific need of identified resident. Timescale for action 07/08/06 14/07/06 3 4 OP3 OP8 14 (1)(d) 13 07/08/06 14/07/06 5 OP7 15 14/07/06 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 Mansions DS0000026500.V301684.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Mansions DS0000026500.V301684.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. 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