Inspection on 05/03/07 for Carnalea Residential Home

This inspection was carried out on 5th March 2007.

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

Carnalea Residential Home 02/03/09

Carnalea Residential Home 19/12/05

Carnalea Residential Home 12/05/05

Carnalea Residential Home 12/01/05

Carnalea Residential Home 19/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Carnalea Residential Home 5-9 London Road Faversham Kent ME13 8TA Lead Inspector Marion Weller Key Unannounced Inspection 5th March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carnalea Residential Home DS0000023368.V332312.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. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carnalea Residential Home Address 5-9 London Road Faversham Kent ME13 8TA 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) 01795 532629 Mrs Betty Florence Wake Mrs Karina Pope Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Carnalea is a privately owned 43-bedded residential care home for older people. The property is a large detached Victorian building, which has undergone substantial conversion. The main building provides accommodation for 34 residents and an annexe attached at both ground and first floor level, accommodates a further 9 residents. The home has a passenger lift and a stair lift, which gives step free access throughout. All of the bedrooms have wash hand basins, television and telephone sockets. There is call bell system in operation, with a call point located in each bedroom for residents to summon assistance. To the rear of the property there is a large and attractive walled garden with seating for residents use. The home is located on the main A2 road approximately one mile from Faversham town centre and railway station and near to a bus route. A number of local shops are within walking distance. There is ample parking for visitors. The home employs care staff working a roster, which provides 24-hour cover. Ancillary staff for catering, maintenance and domestic duties are also employed. Current fees range from £317 to £437 according to assessed personal need. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector between 10:00 am and 3:45 pm. During that time the inspector spoke with some residents, the Registered Provider and the Registered Manager and some of the staff on duty. Some judgements about the quality of life within the home were taken from observations and conversation. Some records and documents were looked at. In addition a tour of the building was undertaken. Responses from residents indicated they were very satisfied with the standard of care the home provided. Statements made during the site visit included: “I feel very happy here. I am settled and well taken care of” “The staff are wonderful, very caring and kind to me” And “I am safe and secure here, they understand what I need help with and what I don’t” The manager and staff gave their full co-operation throughout the site visit. What the service does well: There was an abundance of very positive feedback from residents as to the high quality of service this home provides. Information about the home is easily accessible. The home is effective in helping new residents settle in. Residents’ health needs are well met and medication is given correctly and regularly reviewed. The home enjoys good relationships with other health care professionals. There are effective procedures to protect residents from abuse. Staff were seen to be kind and caring and the manager approachable, experienced and understanding. The Registered Provider has a sound understanding of how the Home operates in practice. This enables her to support and to contribute to the work of the Registered Manager and residents clearly benefit from the ethos, leadership and management approach of the home. Residents enjoy a wholesome and varied menu of meals. Residents’ relatives and friends are always made welcome when they visit. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 6 The home has shown considerable investment and a high level of commitment to providing staff with sufficient skills and knowledge to ensure that residents are well cared for. What has improved since the last inspection? What they could do better: The home needs to review the content of information documents to ensure they continue to meet the demands of regulation in light of The Dept of Health’s revised regulatory requirements. Minor shortfalls were noted in some care plans inspected. The home should avoid fragmentation of information regarding a residents care needs and ensure care plans are signed to evidence the home’s good practice. Residents are largely protected by the home’s policies and procedures regarding the handling of medication. The current minor shortfalls in this area need to be resolved in light of good practice advice to secure residents safety and protection. The home provides freestanding frames that go over the toilet seat; these should be fixed to the floor or alternative support provided. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 7 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. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 123456 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People accessing and using this service have the information they need to make an informed decision about whether the service is right for them. The personalised pre admission assessment means that residents’ needs are clearly identified and planned before they move into the home. Residents are given a written statement of the terms and conditions of their residency that clearly tells them about the service they will receive. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide. The later is in the style of a brochure, which prospective residents are given and which outlines the facilities and services provided in the Home. In addition to this, Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 10 the Registered Manager speaks with prospective residents in order to answer any remaining questions they may have. The manager stated that the home’s information documents are reviewed annually or more frequently if there is a need. The documents were clear, easy to read and informative. They would however benefit from a further minor review. The Dept of Health has changed regulatory requirements recently to clarify in more detail the type of general information about fees and related services that care home providers must include in information documents. The home needs to review the current content of information documents to ensure they continue to meet the demands of regulation. The home has a clear process for undertaking pre admission assessments. The manager visits the prospective resident to make a decision about whether the home can meet the person’s needs. Information is also obtained from other parties, including relevant health care professionals. On admission the individuals initial plan of care is completed by the manager to ensure consistency and clarity of the information gained during assessment. Pre admission assessments form the basis for all residents care plans in the home. Additional assessments are made when the person is admitted to ensure their needs will be fully met. Residents or their representatives are able to visit the home before moving in and some residents said staff had been very helpful in assisting them to settle in. Each resident or their representative was provided with a contract or statement of terms and conditions between the home and themselves. The documents are comprehensive with fees to be charged in evidence. The home’s contracts clearly state the responsibilities of the home and the rights of the resident. Intermediate care is not offered at Carnalea. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are clearly set out in their care plans ensuring that these needs will be met. Residents are protected by the home’s policies and procedures regarding medication. They can be confident that where shortfalls exist the home will review its arrangements and facilities in light of good practice advice to secure their safety and protection. Residents’ privacy and dignity is considered important and their independence is promoted. EVIDENCE: Care plans were seen to be individually maintained in the home and were made available to staff for guidance. Some were inspected closely. The content was easy to understand and covered the health; personal and social Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 12 care needs of individuals. All contained consistent information based on sound assessment. The format the home uses includes residents’ choices and preferences in daily life. Care plans were seen to have been regularly reviewed and changes made where necessary to the main plan. Residents were being weighed regularly and nutritional assessments had been completed. This information was recorded as part of the home’s ongoing assessment and review procedure. Assessments are undertaken, where necessary, to identify any risk associated with maintaining a resident’s skin integrity. There was sufficient evidence to show that individuals’ doctors are called promptly when there is a concern about their health. Daily records were being maintained appropriately and reflected care plan demands. Some minor shortfalls were noted in the care plans inspected. They were not all signed by the resident or their representative to evidence their involvement in the formulation of the plan and their agreement to it. Risk assessments seen were clear, informative and illustrated good systems of work for staff to follow, but they were being maintained separately from the main plan of care. A good practice recommendation would be to ensure that the home avoids fragmentation of information regarding a residents care needs and to ensure care plans are signed to evidence the home’s good practice. The manager stated her intention to address the two issues discussed. Residents said they receive all the assistance they need and are consulted about the contents of their care plans and the assessments undertaken by the home to keep them safe. Care workers were observed assisting residents in a way that was consistent with that described in care plans A monitored dosage system for assisting in residents’ medication administration is used in the home. A separate and largely well-organised medication storeroom was seen. This resource is kept locked and access restricted to appropriately designated individuals only. The home’s Controlled Drugs register was inspected. No residents are currently prescribed Controlled Drugs. Previous records maintained however were sound and entries had been accurately completed. Temperatures were regularly taken of medication storage areas, including cold storage and records were being maintained. Medication administration sheets were inspected. No gaps in recording administration to residents were found. The home had a current medication policy and staff had access to additional guidance documents. All designated medication administrators are trained in administration and some had recently completed a comprehensive 13-week Asset medication-training course. More training is planned. Residents prescribed medication is reviewed by their GP quarterly or earlier, if the situation requires it. Two minor shortfalls to good practice were discussed. Medication delivered to the home was seen not to have been locked away and had been stored under an examination couch in the medication room. Dietary supplements had been stored inappropriately on the floor. When these issues were discussed with Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 13 the manager there was an instant response that she would review the home’s procedures to meet good practice guidelines. The inspector was confident the minor practice issues discussed would be resolved without delay Screening is provided in shared bedrooms to promote individual privacy and dignity. Staff said that they try to ensure individuals are given a choice in relation to sharing a bedroom and are both compatible. It was clear from care plans that the situation is monitored and people’s ongoing agreement to sharing a bedroom is sought. The home carefully considers end of life care and the manager is proposing to develop care plans still further in this direction. This standard was not comprehensively inspected on this occasion. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and opportunities for mental stimulation are regularly offered both individually and collectively to residents. These diversions provide variation and interest. Residents are enabled to exercise choice in their everyday lives and receive a varied and healthy diet. Residents are enabled to maintain contact with friends and family who are made welcome in the home. EVIDENCE: Various social activities take place in the Home. Residents consider themselves to be suitably occupied. The home employs an activities organiser for three days a week has just arranged a further contract with a company that provides meaningful and stimulating activities for all levels of capacity. They will visit the home every two weeks. Residents were said to have enjoyed the first ‘taster session’ arranged. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 15 Residents indicated that the pace of daily life in the home is relaxed and unhurried. There was evidence of residents exercising choice. For example, people stated that they decide for themselves when to get up and when to go to bed and how to spend their day. Residents’ personal choices and likes and dislikes were recorded on their care plans. The home has two attractively laid out dining rooms. Music is played during meals for residents – unobtrusive and pleasant background sound. The manager stated that it makes the meal more of a social occasion for residents. Residents said that they receive good quality meals and they always have enough to eat. The food to have been well prepared at lunchtime and the portions were of an adequate size. Catering staff said that there are always sufficient provisions in the Home to enable all the meals listed on the menu to be prepared. Residents stated that their family and friends are always made welcome in the home. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents consider that their views are listened to and where necessary they are acted upon. Arrangements are in place, which protect residents from abuse, neglect and self-harm. EVIDENCE: The home has a written complaints procedure, which explains how residents and their representatives can make a complaint about any aspect of the facilities and services provided by the home. Residents said that they were confident that any matter they raise will receive attention and if possible will be addressed or reasons given of any limitations. Residents spoken with stated that they felt very safe and secure in the home. The home has received no formal complaints since the last inspection. It was clear that both the Registered Provider and the home’s Manager are proactive in resolving any concerns raised with them at an early stage and they genuinely want people to be satisfied with the service they receive. Currently the home does not record minor concerns raised with them to further inform the quality assurance or business planning process. A discussion took place as to how best this could be addressed; the manager spoke of her intention to complete this aspect of the quality assurance process in future. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 17 The manager and staff had a sound understanding of what constitutes good care practice. As part of this, they are aware of the need to be alert to instances, which might jeopardise the well being of a resident. They are equally aware of the various agencies external to the home to which reference can be made should they become concerned about a service user’s wellbeing. The home has adopted Kent & Medway’s Adult Protection Policy and uses this as the basis of their safeguarding practice. The home’s Adult Protection Policy and Procedures together with the lead agencies good practice documents are included in staff induction. All staff receive training in safeguarding procedures and Adult Protection issues. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, well maintained, clean and comfortable environment in which good standards of décor and furnishings are maintained. EVIDENCE: Residents said that they were very comfortable living in Carnalea and that they consider the accommodation to be clean, homely and welcoming. A tour of the building was undertaken with the manager. There were an adequate number of shared use toilets and bathrooms to enable residents to access these facilities without having to wait or otherwise be inconvenienced. Some bathroom fittings are being updated as part of the current building work. The home provides freestanding support frames that go over the toilet seat in Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 19 some toilets; it is recommended that these be fixed to the floor to eliminate avoidable falls. This was discussed with the manager. There were various items of equipment in place to assist staff to meet the needs of residents who experience reduced mobility. These include things such as hoists in the bathrooms and banister rails along hallways. Care workers say that enough provision has been made to enable them to safely undertake all aspects of their work. Infection control is good in the home and policy and procedures were seen to be adhered to. Communal toilets evidenced paper towels and liquid soap in use. There is a call bell system installed. This means that there are call points in most areas from which residents can summon care workers, should their assistance be required. Residents like their bedrooms. They said that they have enough facilities in them to use them as bed sitting areas in the manner envisaged by the Standards. I had the opportunity to see several bedrooms and noted them to be very comfortable and pleasant spaces. All had been personalised to reflect the preferences and personal interests of their occupants. The accommodation for residents was comfortably warm. Residents confirmed that this was always the case. Care workers said that there is an adequate supply of hot water at all times. The home’s kitchen was clean and orderly. Comprehensive cleaning schedules were in evidence. The Environmental Health Officer had visited the home on the 24/1/07. It was recommended on that visit that eggs to be kept in the fridge and that they are well cooked for this vulnerable client group. It was noticed that the home fully complies with the advice given. The Environmental Health Officer issued the home with a Clean Food Award. The owner is now in phase 2 of a programme of building work, which eventually will see the current accommodation extended to provide 8 new ensuite bedrooms. Part of this programme entails work, which will reconfigure two of the existing bedrooms. This is being done to provide more usable floor space in these rooms. The home’s kitchen has now been moved from the back to the front of the house and the area is now fully operational. There is a new fire escape installed. To accommodate any additional pressure during the course of the building work, overall resident occupancy has been kept low during this time. On the day of the site visit there were 31 residents in the home. Full capacity is currently 43. Residents spoken with reported no significant disruption to their daily life or any inconvenience caused to them during the course of this work, which considering the size of the project is commendable and illustrates careful and considerate project management on behalf of the Registered Provider. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 20 One resident spoken with found it quite pleasant to watch the workmen from her bedroom window. “Fascinating”, she said. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by a dedicated staff team who are well supported and supervised. The home continues to effectively train and develop its staff to ensure residents’ needs are met at all times. EVIDENCE: There was four care staff on duty to respond to residents needs for assistance during the day. Catering, domestic and a part time activity organiser are also employed. At night, there are three waking care workers on duty. It was clearly evident that there is sufficient staff to enable residents needs to be met in a timely and reliable manner. Staffing rosters were being suitably covered to ensure staff absence had no impact on residents care. More than half of the care workers employed in the home had acquired a National Vocational Qualification in Health and Social Care. This level meets the specification required by the Standards. The Manager evidenced robust recruitment procedures. These are designed to ensure that all members of staff employed in the home are suitable to be Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 22 entrusted with access to residents who may be vulnerable. CRB and POVA checks for all staff were seen. Staff spoken with were aware of their roles and responsibilities. There are clear lines of accountability in the home. Staff appeared happy working there and felt they had the necessary skills to meet the requirements of their role. The Manager said that all new care workers receive introductory training. This is designed to ensure that they have the basic competencies necessary to enable them to work without direct supervision. The home’s induction programme was inspected and found to be comprehensive. In addition to introduction training, existing care workers undertake a number of training courses, which are designed to enhance their capacity to deliver care. The Registered Provider and the Registered Manager are aware of the responsibility placed upon them to ensure that all care workers are validated as having the competencies necessary to enable them to effectively support residents. It is a recommendation that the owner introduces a training matrix to provide the home with a clear overview of staff training completed, training planned and update training required for staff. The manager stated her intention to undertake this work. Staff files held individual training records and certificates gained. Staff supervision and appraisal was seen to take place on a regular basis. Care workers were observed assisting residents during the site visit, they demonstrated that they were competent to respond effectively and reliably to requests for assistance. It was also observed that care workers were kind and considerate in their approach to residents. Overall the home evidenced an effective staff team who worked well together and who received sound line management and support. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a site visit to this service. Residents benefit from the home being managed by someone who is experienced, competent and resident focussed. The health, safety and welfare of residents are promoted and protected. Residents benefit from the staff group who receive formal supervision, identification of training needs and regular support. EVIDENCE: The Registered Provider has a sound understanding of how the home operates in practice. This enables her to support and contribute to the work of the Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 24 Registered Manager. In turn, the Registered Manager has completed both of the two National Vocational Qualifications, which the Standards require. There are clear lines of accountability in the home and everyone spoken with clearly understood their role and responsibilities. Residents spoken with said that the home is run without there being any intrusive rules or routines. This means that they can continue to experience a normal home life of their own choosing. The Registered Provider operates a system by which residents are invited to comment about their home. The Registered Manager said that all items of equipment in use in the home remain in good working order and are regularly serviced. The Registered Provider continues to maintain a suitable system which is designed both to prevent the occurrence of a fire safety emergency and to manage one effectively should the need arise. The manager stated that the Kent Fire and Rescue Service have not recommended the introduction of any fire safety equipment additional to that which already is in operation in the home. The safety equipment in place had been regularly serviced and maintained. The Registered Manager said that she had completed a review of the premises in order to identify any potential hazards, which might compromise the health and safety of both residents and members of staff. Where found they had been eliminated or risk assessed. However, The home provides freestanding support frames that go over the toilet seat in some toilets; it is recommended that these be fixed to the floor to eliminate avoidable falls. The owner and the manager are experienced and run the home competently and in the best interests of residents. They are both keen to further develop the service in line with good practice and the demands of Regulation. Residents and staff said they found the manager and the owner approachable, supportive and knowledgeable. The atmosphere in the home was calm and pleasant. Residents spoken with were happy, contented and felt well looked after and cared for. All of the home’s policies and procedures were comprehensive and had been reviewed regularly in line with good practice advice and current legislation. There was discussion on the day of the inspection about improving some minor areas of medication storage in the home. The manager stated her intention to address the issues raised by the inspector as quickly as possible. The home’s records were stored securely in locked cabinets and in a room, which was kept locked when unoccupied. All staff understood how important it was to maintain residents’ privacy and confidentiality. The home encourages residents’ families and representatives to manage their finances. Neither Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 25 residents nor their families expressed any concerns about the home’s management of monies or valuables. All staff were clearly competent and aware of the help and support residents needed. Training records evidenced all mandatory training and updates having been completed by staff. The manager evidenced a high level of commitment to staff training and development and the home regularly undertakes staff supervision and appraisal. The home would benefit from the formulation of a staff-training matrix to evidence their good practice. This was discussed with the manager. The Manager and Registered Provider undertakes an annual quality assurance exercise to inform forward planning for the service and also speaks regularly with residents and their representatives as to the service offered to them. Residents meetings regularly take place. The minutes of meetings were available to view and had been shared with residents. The home notifies the Commission in timely manner of any issue that affects the welfare of residents. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 26 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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 27 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 Home’s 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. Refer to Standard OP1 Good Practice Recommendations The manager should review the content of the home’s information documents to ensure they continue to meet the demands of regulation in light of The Dept of Health’s revised regulatory requirements. Minor shortfalls were noted in some care plans inspected. The home should avoid fragmentation of information regarding residents care needs and ensure care plans are signed to evidence the home’s good practice. It is strongly recommended that the manager fulfil the stated intention of reviewing the medication administration storage facilities in the home in line with good practice advice to secure residents safety and protection. It is a recommendation that the manager introduces a training matrix to provide the home with a clear overview DS0000023368.V332312.R01.S.doc Version 5.2 Page 28 2. OP7 3. OP9 4. OP30 Carnalea Residential Home of staff training completed, training planned and update training required for staff. 5. OP38 The home provides freestanding frames that go over the toilet seat, it is recommended that these be fixed to the floor or alternative support be provided. Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carnalea Residential Home DS0000023368.V332312.R01.S.doc Version 5.2 Page 30 - 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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