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Inspection on 23/02/07 for Carlton Road Care Home

Also see our care home review for Carlton Road Care Home for more information

This inspection was carried out on 23rd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The ethos of Carlton Road Care Home is to promote independence and to encourage service users to work towards their own identified and achievable goals. Service users are supported to follow leisure pursuits and college courses of their choice and work placements are also pursued. With the development in communication aids at the home the service users with greater support needs now have increased opportunity to develop communication and social skills. Care plans include what support individual`s require in order to access the community and its facilities. By talking with service users and staff it was apparent that service users have regular opportunities to access community facilities, including going down the pub, going swimming, accessing the library and shops, going to college. Providing this support is regarded as a fundamental part of staff duties. Service users are offered a wide range of activities and they receive personal support in the way they prefer and require. Service users healthcare needs are met and medicine management within the home was satisfactory. Service users needs are assessed, which include their wishes and preferences to ensure that staff can support them, in a way, which meets their individual and specialist needs. Service users are provided with a contract. Service users are supported by an effective care plan structure, which enables them to participate and make decisions about their daily lifestyle and promotes independence and responsible risk taking where they are able to do so. Complaints procedures are accessible to service users. Service users are protected from abuse, neglect and self- harm. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager has sound knowledge of both strategic and financial planning and review. The manager is visionary in his approach to the service and communicates a clear sense of direction. Service users benefit from a well run home with good record keeping. Service users are confident their views underpin all self-monitoring review and development of the home. The health, safety and welfare of service users are promoted and protected. A well-supported, well-trained, fully supervised and committed staff team supports Service users. Robust recruitment practice ensures service users safety. Service users live in a home that is appropriate to their specific needs, is clean, smells fresh and staff adheres to infection control policies to reduce the risk of infection.

What has improved since the last inspection?

Medications profiles have been further developed. The plaster damage throughout the home has been investigated and the lounge area in 183 repaired and refurbished. New flooring has been provided in 181. Improvements have been made in relation to maintenance work records and risk assessments for surface temperatures. Copies of the electrical certificate and the fire risk assessment were available in the home for inspection. One first floor bedroom window has been replaced which is restricted. A new facsimile is on order and due to be sited at the home, the week after the inspection.

What the care home could do better:

Four good practice recommendations have been made. Further develop ways to ensure service users and visitorsare informed how to access a copy of the inspection report. Where prescriptions are handwritten on the medication administration record, this should be checked and signed by a second staff member Look at innovative storage ideas to prevent the need to climb and reach to high shelving. Provide training for staff in Equality and Diversity.

CARE HOME ADULTS 18-65 Carlton Road Care Home 181-183 Carlton Road Worksop Nottinghamshire S81 7AD Lead Inspector Jayne Hilton Key Unannounced Inspection 23rd February 2007 11:15 Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Road Care Home Address 181-183 Carlton Road Worksop Nottinghamshire S81 7AD 01909 473 831 01246 810207 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) NORSACA Andrew Graham Beech Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 Brief Description of the Service: 181/183 Carlton Road supports 9 adults with learning disabilities and who have an autistic spectrum disorder. The service is owned by NORSACA (Nottingham Regional Society for Adults and Children with Autism). Accommodation is in 2 adjoining houses. There is linked access between the houses but through access is encouraged to be for emergencies only. 181 Carlton Road accommodates five service users with around the clock support needs. 183 Carlton Road accommodates four service users who are identified as being more independent. As part of the home’s ethos, some service users at 181 Carlton Road have progressed and have chosen to move on to 183, the semiindependent house. All of the bedrooms are single. The home has recently registered from 8 to 9 service users, with a 4th bedroom, which has e-suite facilities, in the semi-independent house. The home is sited within walking distance of town centre amenities. The fees charged are reported to be £1025.00 a week. This information was provided by, the registered manager on 23/02/07. Service users are expected to contribute to their holidays; chiropody, magazines, newspapers and activities and day care charges are additional. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took any previous information held by C.S.C.I. about the home into account. The inspection included a site visit, which took place over four hours. The main method of inspection used was called case tracking. This involves selecting a proportion of service users and tracking the care they receive through the checking of records, discussions with staff that care for them and observation of care practices. On the day of the visit service users were only present periodically, as they attend various activities throughout weekdays. A partial tour of both houses was also conducted which included looking at bedrooms, communal areas, kitchens and the laundry facilities. Documentation was sampled and the care records of two service users were examined. What the service does well: The ethos of Carlton Road Care Home is to promote independence and to encourage service users to work towards their own identified and achievable goals. Service users are supported to follow leisure pursuits and college courses of their choice and work placements are also pursued. With the development in communication aids at the home the service users with greater support needs now have increased opportunity to develop communication and social skills. Care plans include what support individual’s require in order to access the community and its facilities. By talking with service users and staff it was apparent that service users have regular opportunities to access community facilities, including going down the pub, going swimming, accessing the library and shops, going to college. Providing this support is regarded as a fundamental part of staff duties. Service users are offered a wide range of activities and they receive personal support in the way they prefer and require. Service users healthcare needs are met and medicine management within the home was satisfactory. Service users needs are assessed, which include their wishes and preferences to ensure that staff can support them, in a way, which meets their individual and specialist needs. Service users are provided with a contract. Service users are supported by an effective care plan structure, which enables them to participate and make decisions about their daily lifestyle and promotes independence and responsible risk taking where they are able to do so. Complaints procedures are accessible to service users. Service users are protected from abuse, neglect and self- harm. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 6 manager has sound knowledge of both strategic and financial planning and review. The manager is visionary in his approach to the service and communicates a clear sense of direction. Service users benefit from a well run home with good record keeping. Service users are confident their views underpin all self-monitoring review and development of the home. The health, safety and welfare of service users are promoted and protected. A well-supported, well-trained, fully supervised and committed staff team supports Service users. Robust recruitment practice ensures service users safety. Service users live in a home that is appropriate to their specific needs, is clean, smells fresh and staff adheres to infection control policies to reduce the risk of infection. What has improved since the last inspection? What they could do better: Four good practice recommendations have been made. Further develop ways to ensure service users and visitors Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 7 are informed how to access a copy of the inspection report. Where prescriptions are handwritten on the medication administration record, this should be checked and signed by a second staff member Look at innovative storage ideas to prevent the need to climb and reach to high shelving. Provide training for staff in Equality and Diversity. 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 Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed, which include their wishes and preferences to ensure that staff can support them, in a way, which meets their individual and specialist needs. Service users are provided with a contract. EVIDENCE: Service users needs are assessed, which include their wishes and preferences to ensure that staff can support them, in a way, which meets their individual and specialist needs. Service users are provided with a contract. Through discussion with the staff it is evident that the home can meet the assessed needs of individuals admitted to the home. The cultural needs (including dietary preferences) of a service user of AfricanCaribbean origin are recognised and met. There is regular access and consultation with specialist professionals such as a consultant psychiatrist. There was evidence of development in meeting the communication needs of service users, with speech and language input and the subsequent production of communication tools such as pictures and symbols. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 10 The terms and conditions/contract between the home and service user were seen within the plan. The manager and staff spoken with said that service users and relatives are informed in the homes newsletter about inspections and that they can access a copy of the report. The manager could not evidence this on the day of the inspection however as the computer had broken and the template not available, neither could previous copies of the newsletter be located. It is recommended that the registered person explores other ways to ensure service users and visitors to the home are informed how they can access a copy of the inspection report. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by an effective care plan structure, which enables them to participate and make decisions about their daily lifestyle and promotes independence and responsible risk taking where they are able to do so. Limitations and restrictions on freedom were also recorded. EVIDENCE: Three service users were present at the time of the inspection and there was evidence through documentation and observations during the inspection that staff, provide service users with the information, assistance and communication support they need to make decisions about their own lives. Signs, symbols and pictures are being used to enable service users with communication needs, to help choose meals and menus and what activities they would like to participate in. Advocacy services are available to service users if they wish to use them. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 12 Through discussions with staff it became apparent that a sanction/limitation had been imposed on a service user, which in effect is a limitation /restrictions that had been implemented, this was documented in the individual support plan. Service users spoken with confirmed they are consulted and informed about proposed events in the home. There are regular residents meetings where issues about the running of the home are discussed. Service users’ views are not only obtained as part of NORSACA’s quality assurance review but there is also opportunity for service users to be on the working party that visits different services to obtain the views of its residents, staff and relatives. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff, enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 14 It was clearly evident throughout the inspection that staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. The ethos of Carlton Road Care Home is to promote independence and to encourage service users to work towards their own identified and achievable goals. Service users take it in turns to assist staff with the weekly food shop. Service users are supported to follow leisure pursuits and college courses of their choice and work placements are also pursued. With the development in communication aids at the home the service users with greater support needs now have increased opportunity to develop communication and social skills. Care plans include what support individual’s require in order to access the community and its facilities. Some service users need a member of staff to accompany them into town whereas other service users (all in the semiindependent) have progressed and been risk assessed as being able to go out into town independently. By talking with service users and staff it was apparent that service users have regular opportunities to access community facilities, including going down the pub, going swimming, accessing the library and shops, going to college. Providing this support is regarded as a fundamental part of staff duties. Service users are offered a wide range of activities. All service users have the opportunity to have holidays and these are taken in small groups throughout the year. Communication tools were seen for service users to make choices about holidays and which staff they would like to accompany them. Various trips were arranged. Local trips are taken also and people have the opportunity for meals out and pub visits. Leisure activities are included in the care planning process and interests are recorded. Service users spoken with said that members of staff always knock on the door and wait for an answer before entering their room. From observation during the inspection it was evident that staff naturally interact with service users. Staff were observed engaging with service users who have significant communication difficulties. Service users spoken with said that they could choose when they want to be alone or in company and when not to join an activity. Service users have responsibilities for household tasks and these are recorded and agreed in individual care plans. Service users confirmed that the cooking is shared and each service user has a day when they clean their own rooms and when they vacuum and polish the house. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 15 Evidence was provided that service users are supported to maintain relationships. Service users visit relatives and visitors are made welcome at the home. Menus were examined and appeared to be varied and nutritious. These are planned and offer two choice options, which are fully recorded. Options also include a vegetarian choice. A tool has been devised for this purpose and combined food safety check records. A menu in pictorial format is also displayed. The meal options on the day of the inspection were roast gammon or fish fingers and chips. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require and service users healthcare needs are met. Medicine management within the home was satisfactory. A good practice recommendation is made for two staff to sign the medication administration chart where prescription is handwritten. EVIDENCE: All service users have a designated key worker. Service users who were spoken with know who their key worker is and what they are for. The service users spoken with are happy with the support they are given and feel they have control in their lives. Care plans indicate likes and dislikes and the different forms of support that are required for each individual. For example, where ‘hands on’ support is not applicable, prompting is. Care plans record when other specialist support has been obtained. Healthcare needs of service users appeared to be well met. One service user has diabetes, which is controlled by medication. Routine, blood-monitoring Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 17 checks are carried out by the nurse at the medical centre. Attention is needed to ensure that the care plan includes detail about arrangements for blood sugar monitoring and that these visits are consistently evaluated within the review process. Healthcare needs of service users are well monitored and documentation is kept of routine chiropody dental and ophthalmic checks. Weight records now have a comment/action section. There was now more information regarding medication in the service users files, and a medication profile section has been further developed to include details of medication reviews, adverse effects and contraindications and changes of medication. There are no service users currently self-medicating. The policies for medication management have been reviewed and updated to meet the Royal Pharmaceutical society’s Guidance for medicine administration in care homes. A visible drug error policy was seen. Storage temperatures of medicines were now being monitored. Medication is otherwise stored securely. The medicine keys are kept securely and are now kept separate to other keys in the home. Staff handwrites the medication administration records and these need to be checked and signed by two members of authorised staff to minimise error. It is also recommended that two signatures be obtained for receipt of new prescriptions. Staff receive appropriate training and the manager confirmed competency assessments were undertaken periodically. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Complaints procedures are accessible to service users. Service users are protected from abuse, neglect and self- harm. EVIDENCE: There is a complaints procedure and this is displayed in both 181 and 183 Carlton Road. Complaints procedures are in symbol and pictorial versions also. There has been no complaint recorded since the previous inspection. A formal system has been introduced for documenting and filing complaints. The complaints procedure has appropriate time scales for response and action. A service user spoken with confirmed he would tell staff if he was not happy. Relevant policies and procedures are in place for adult protection. The NCVAP [Nottinghamshire Committee For Vulnerable Adults Procedural guidance manual] is held in the home and the manager reported at the previous inspection that he had attended training and updated the file. Refresher training in adult protection for other staff is planned over the next twelve months. Policies for dealing with challenging behaviour and individual reactive strategies are included within the care plans. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is appropriate to their specific needs, is clean, smells fresh and staff adheres to infection control policies to reduce the risk of infection. EVIDENCE: Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 20 Carlton Road Care Home is made up of 2 adjoining houses, 181 and 183 Carlton Road. Given that each house provides a different level of support and is treated as separate houses, this helps to ensure that the environments at both 181 and 183 are relaxing and homely, with adequate communal space. The kitchens in each house are spacious and equipped to enable service users to be supported in using facilities and developing cooking and daily living skills. There is good access from the home to local amenities. The premises appeared on the whole safe, comfortable, and bright. A new path has been laid in the rear yard. Some plaster cracks/structural has been rectified and the lounge in 183 has been redecorated and new flooring was to be fitted on the day of the inspection. Ongoing remedial work is planned. The bedrooms were all very personalised to reflect individual service users’ tastes. Bedrooms seen had pictures and posters displayed on walls and further shelving where requested. The rooms have sufficient furniture and fittings sufficient and suitable to meet the needs of the service users. Innovation is needed to ensure storage/shelving is not placed too high and that service users and staff do not have to climb to reach. All bedrooms are lockable. There are lockable facilities available in bedrooms. There is also the choice to have a mini-fridge. Except for one bedroom with en-suite, there are shared facilities for the other service users. There is the choice of a shower or a bath in both houses. The facilities are adequate in meeting the needs of the service users and offering sufficient personal privacy. There are no specific aids and adaptations in the home as all current service users are fully mobile and have no assessed needs in relation to these. Radiator covers have been fitted to some radiators and some are of the low surface type and all windows have restrainers fitted. The home was found to be clean and a good standard of hygiene observed in practice. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A well-supported, well-trained, fully supervised and committed staff team supports Service users. Robust recruitment practice ensures service users safety. EVIDENCE: A copy of the staff rota was viewed and this evidenced generally three support staff throughout the weekdays and two on at a weekend with one staff member on sleep in and on call arrangements. Staffing levels are arranged around the number of service users who are at the home at the time. There were no issues raised at the visit in relation to staffing levels. NORSACA has its own thorough recruitment policy and procedures. Four personal staff files were examined and found to contain the required documentation. The service sees induction and any probationary period as being an extension of recruitment. There are contingency plans for cover for vacancies and sickness. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 22 All staff receive mandatory training for infection control, health and safety, first aid, fire safety, food hygiene and manual handling and additional training is also provided in Challenging behaviour, managing diabetes, epilepsy, food and nutrition, adult protection and working with people with autistic spectrum disorders and Protection of Vulnerable Adults. Future training should include Equality and Diversity. Staff are undertaking NVQ training and training for staff that work with people with a learning disability. All staff spoken with understood the specific nature and uniqueness of the home, its aims and objectives and how the care will be delivered. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home with good record keeping. Service users are confident their views underpin all self-monitoring review and development of the home. The health, safety and welfare of service users are promoted and protected EVIDENCE: The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager has sound knowledge of both strategic and financial planning and review. The manager is visionary in his approach to the service and communicates a clear sense of direction. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 24 There was evidence of a range of quality assurance tools used by the home, including the quality network system mentioned earlier in the report. Regulation 26 visits are carried out. The home also uses the Quality Tree folder. Consultation with service users is also part of the day-to-day running of the home and as part of the service user meetings. A sample of service users financial records was examined and found to be satisfactory with good auditing systems in place. Records examined on the day were satisfactory, these included fire records, accident, incident, water outlet temperatures, Portable appliance test records, systems in place for prevention of legionella electrical circuit testing and The Gas safety Certificate. There is a health and safety policy in place and generic risk assessments were viewed. The fire risk assessment was now completed. Staff and service users spoken with were aware of the importance of wearing personal protective equipment for tasks in the home. Food safety practices appeared satisfactory and the home was clean and hygienic. Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 4 4 4 4 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008815.V330365.R01.S.doc 4 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carlton Road Care Home Score 4 4 3 X 4 X 4 X X 4 X Version 5.2 Page 26 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. 1. 2 3 4 Refer to Standard YA5 Good Practice Recommendations Further develop ways to ensure service users and visitors are informed how to access a copy of the inspection report. Where prescriptions are handwritten on the medication administration record, this should be checked and signed by a second staff member Look at innovative storage ideas to prevent the need to climb and reach to high shelving. Provide training for staff in Equality and Diversity. YA20 YA26 YA35 Carlton Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Road Care Home DS0000008815.V330365.R01.S.doc Version 5.2 Page 28 - 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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