This inspection was carried out on 7th June 2005.
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.
CARE HOMES FOR OLDER PEOPLE
Carlton Nursing Home Rawdon Cragg Woodlands Drive Rawdon LS19 6JZ Lead Inspector
Michael Smithson Unannounced 10 am 7 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Carlton Nursing Home Address Rawdon Cragg, Woodlands Drive, Rawdon, Yorkshire, LS19 6JZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2509633 0113 2509633 Mr John Lamb and Mrs Helen Lamb Miss Jennifer Teresa Clegg Care home with nursing 29 Category(ies) of Mental Disorder (29), Dementia (29) registration, with number of places Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 60 years and over Date of last inspection 2 March 2005 Brief Description of the Service: The Carlton Nursing Home is a converted Victorian building situated in a residential area on the borders of Leeds and Bradford. Personal care with nursing is provided for older people with dementia or mental disorder. Both men and women are catered for in this 29 bedded home which can provide single bedrooms as well as shared accommodation.The home is set in large grounds, which are not accessible to service users without close supervision. The area is purely residential and as such there are no convenient local shops or other amenities. The home is not accessible by public transport. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection the first for this inspection year. The second will be an announced inspection. Copies of this inspection report and reports from previous visits are available either from the home or from the CSCI website. The inspection took place over the morning and afternoon and focused on the environment, care records and discussions with the staff and service users. The registered manger was not present during the inspection. A number of records were locked in the manager’s office and were not available. The majority of the service users do find it difficult to express their opinions about the home, however those who are able felt the staff provided a good standard of care. The staff were observed during the inspection and their friendly manner helped to put service users at ease and reduce tension and anxiety. What the service does well: What has improved since the last inspection? Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 6 Some of the requirements made at the last inspection were not checked due to the relevant records not being available. These will be checked at the next inspection. There have been no significant improvements to the areas covered at this inspection. The home had previously achieved good standards. 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 Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 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 standard(s) 1, 3 and 4. Service users or relatives are provided with information to enable them to make an informed choice about the home. EVIDENCE: A statement of purpose and user guide are available. The information has recently been reviewed and is available to placing agents. Service users are admitted in line with the categories of registration. An initial assessment form is completed prior to or at the admission. The last service user admitted to the home had an assessment completed prior to admission. At the last inspection it was noted that private fee paying service users were not issued with the homes terms and conditions of residency. The person dealing with the issuing of terms and conditions was not present during this inspection. The information will be checked at the next announced inspection. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7 and 8. The health and personal care needs of service users are well met by the staff at the home. EVIDENCE: The records for 3 service users were checked. All the care records were accurate and kept up to date. Basic assessments had been completed together with a more detailed activities for daily living. Specific health care assessments are completed including, pressure care, nutrition, manual handling and continence. Specific risk assessments are completed if needed. These include for falls and cot sides. The care plans include individual aims and objectives for service users. They are regularly updated by the staff team. A clinical audit system is in place to make sure that all the information is kept up to date. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 15. The home provides a well balanced and varied diet for service users. EVIDENCE: The menus are organised on a 4 weekly basis and are changed twice a year. A choice is offered at breakfast and at tea. An alternative would be offered at lunch. The cook said there were no special diets being provided, however a number of service users do require a soft option and assistance with feeding. The food stocks were plentiful and contained fresh, frozen and dry produce. The 2 cooks work alternate shifts on a 5 on, 5 off pattern. Both have obtained Basic Food Hygiene certificates. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 18. The home does not fully provide staff with sufficient training to protect service users from abuse. EVIDENCE: At the last inspection is was identified as a requirement that more staff must be provided with adult protection training. Speaking to the staff on duty it appeared no progress had been made. A number of new staff had been employed so it is now important that more adult protection training is provided. Complaints were not covered as part of this inspection. It will be included at the announced inspection. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The environment does not at present provide facilities and surroundings that are pleasant and well maintained. EVIDENCE: A full building inspection was undertaken during this visit. The facilities are available over 2 floors. The communal areas are all located on the ground floor. The bedrooms on the ground and first floors. The building is an old adapted property which does require constant up keep. A maintenance man is employed to maintain the premises. The provider was present for part of the inspection and was able to highlight areas of planned improvements for the building. New chairs have been purchased for the communal areas and the conservatory chairs will be used in bedrooms. All the bedrooms are in need of refurbishment. The provider has completed bedroom 1 to the standard she wishes to complete all the bedrooms. The bedroom has been redecorated with new furniture and bedding
Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 13 provided. If all bedrooms are done to this standard the personal space for service users will be greatly improved. A number of minor concerns and repairs are required. These include the following: All the wardrobes in bedrooms must checked to make sure they are firmly secured. All items stored on top of wardrobes must be removed. Chair cushions were missing from the majority of the bedroom chairs. These must be returned or replaced. Bedroom 3 Screening curtains are required. Bedroom 8 There was an odour in this room, which requires attention. Bedroom 9 The drawer in on of the wardrobes is broken and must be repaired. One of the wardrobes is placed next to the en-suite and restricts access to the bathroom. It must be removed to a more suitable area. Bedroom 11 The main bulb must be replaced. Bedroom 12 Water damage was evident in the corner of the bedroom and requires attention. The curtain requires replacing. Bedroom 16 The sink light in must be replaced. Bedroom 19 Part of the wallpaper in the en-suite has been torn off and needs redecoration. The curtain screening must be replaced. Toilet first floor The door handle on the inside has broken and must be repaired or replaced. The provider made note of all the repairs highlighted above during the inspection and assured the inspector that they would be dealt with promptly. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 14 Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. Due to lack of access to certain records the inspectors found it difficult to make a clear judgement regarding recruitment and training. EVIDENCE: The staff recruitment records and staff training records were not available during the inspection. The information was locked in the manager’s office. The registered manager was not present during the inspection. There have been a number of staff changes since the last inspection. I spoke to one member of staff who had recently been employed at the home. The member of staff had no previous experience of care work. She did confirm she had completed a CRB check and 2 references had been provided. She had completed a basic induction including manual handling training and had shadowed a more experienced member of staff for the first week. She has worked at the home for 6 weeks but had not yet received any fire safety training. She had not been on duty when the alarms were being tested or when a fire practice had been undertaken. This must be addressed. Due to a number of staff having left the home that had completed NVQ 2 the percentage of staff having achieved level 2 has reduced. Arrangements are being made to increase the numbers of NVQ 2 qualified staff among the among existing and new staff. The new member of staff spoken to at the inspection confirmed she would be undertaking NVQ 2 in the near future.
Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 37. The management and administration of the home is geared to meet the needs of the service users. EVIDENCE: The registered manager was not present during this inspection. A number of the records were not available. The records seen were well organised and were kept up to date. A staff meeting had recently been held due to the changes in the staff team. The staff had the opportunity to include items for the agenda and raise issues regarding the home. Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 2 3 2 3 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x 3 x x x x 3 x Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation Reg 17(2) Requirement All private paying service users or relatives must be provided with a copy kept at the home for inspection. Adult protection training must be provided for all staff. All the wardrobes in bedrooms must checked to make sure they are firmly secured. All items stored on top of wardrobes must be removed. Toilet first floor The door handle on the inside has broken and must be repaired or replaced. Bedroom 3 Screening curtains are required. Bedroom 8 There was an odour in this room, which requires attention. Bedroom 9 The drawer in one of the wardrobes is broken and must be repaired. One of the wardrobes is placed next to the en-suite and restricts access to the bathroom. It must be removed to a more suitable area.
Version 1.30 Page 19 Timescale for action Immediate Action 01/09/05 Immediate Action 2. 3. OP18 OP19 Reg 13(6) Reg 4(a) 4. OP21 Reg 13(4)(a) Reg 23(2)(b) Reg 23(2)(c) Reg 23(2)(d) Reg 16(2)(c) Immediate Action 01/09/05 5. OP23 Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Bedroom 11 The main bulb in must be replaced. Bedroom 12 Water damage was evident in the corner of the bedroom and requires attention. The curtain requires replacing. Bedroom 16 The sink light in must be replaced. Bedroom 19 Part of the wallpaper in the ensuite has been torn and must be replaced. The curtain screening must be replaced. Chair cushions were missing from the majority of the bedroom chairs. These must be returned or replaced. Fire safety training must be provided for all new staff. 50 of the care staff must achieve NVQ level 2 by the end of 2005. 6. OP25 Reg 16(2)(c) Reg 23(4) Reg 18 01/09/05 7. 8. OP28 OP30 Immediate Action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Carlton Nursing Home J52 S1326 Carlton Nursing Home V228786 070605 Stage 4.doc Version 1.30 Page 20 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
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