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Inspection on 26/06/07 for Carntyne Residential Care Home

Also see our care home review for Carntyne Residential Care Home for more information

This inspection was carried out on 26th June 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.

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 manager and her staff treat the residents with great respect, and the home is run in a very resident-centred way. Residents choose how they wish to spend their day. Residents` privacy is respected and their dignity protected. Residents can use local services, shops and other facilities outside the home. Residents can have visitors whenever they wish, and can see them in private. Residents` health needs are met through careful monitoring. Residents get a good, balanced diet, with choice, and are very happy with the quality of the food and the cooking. Any concerns or complaints are taken seriously and are looked into promptly (very few complaints are received). Residents say that they feel confident that they can share any concerns with the staff, and that the staff would sort out any problems they may have. All staff have been trained in moving & handling, health & safety, food hygiene, fire safety and first aid. The building is clean, pleasant, warm and safe, and is well decorated and furnished. It is well maintained. There are enough staff, and the staff group is very stable, with little turnover. Residents say that the staff are always very kind, caring and hard working. Any requirements made in inspection reports are always taken seriously and are acted upon quickly.

What has improved since the last inspection?

A lot of staff time and effort has gone into improving the social activities available to the residents. There is now much more social stimulation, and the residents say that they appreciate this. The home`s policy on protecting residents from abuse of any kind has been improved. It now clearly shows how staff must respond to any allegation that comes to their attention. The home has tightened up its staff recruitment practices, and it is now even more careful not to employ any unsuitable staff. Staff are now being given proper supervision at the frequency required. New staff are now being given better induction training, and all new staff are then being put on National Vocational Qualification (NVQ) training. The building has been given a `risk assessment` to check that it is as safe as it can be.

What the care home could do better:

Fuller assessments of a new resident`s needs must be completed before that person is admitted to the home. All assessments must be fully completed, signed and dated. Every need identified in an assessment must have a care plan drawn up, to show how that need will be met. Extra care is needed in the medication records to make sure that staff always sign every time a medicine is given, and when there have been any changes to the medication records. Those staff who have not been given training in `safeguarding` residents must have this arranged as a priority.

CARE HOMES FOR OLDER PEOPLE Carntyne Residential Care Home Hencotes Hexham Northumberland NE46 2EE Lead Inspector Alan Baxter Key Unannounced Inspection 26th June 2007 09:30 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 Carntyne Residential Care Home DS0000000601.V337967.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. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carntyne Residential Care Home Address Hencotes Hexham Northumberland NE46 2EE 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) 01434-600195 01434 600195 carntynehome@aol.com Sisters of Mercy Mrs Jennifer May Dodds Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Carntyne is an old building providing personal care for older people. It is situated close to the centre of Hexham and convenient for public transport. The home is registered to provide care for up to 18 older people. Accommodation is provided over 3 floors. All bedrooms are single, some with ensuite. There are several lounges and a pleasant dining room. The garden is large and enclosed at the rear of the home and can be used by residents and their visitors. All areas are accessible by disabled people. There is a lift to all 3 floors. Weekly fees are from £400 to £409.40. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 29th November 2005. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 26th June 2007. During the visit we: • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit.. • • We told the senior person on duty what we found. What the service does well: The manager and her staff treat the residents with great respect, and the home is run in a very resident-centred way. Residents choose how they wish to spend their day. Residents’ privacy is respected and their dignity protected. Residents can use local services, shops and other facilities outside the home. Residents can have visitors whenever they wish, and can see them in private. Residents’ health needs are met through careful monitoring. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 6 Residents get a good, balanced diet, with choice, and are very happy with the quality of the food and the cooking. Any concerns or complaints are taken seriously and are looked into promptly (very few complaints are received). Residents say that they feel confident that they can share any concerns with the staff, and that the staff would sort out any problems they may have. All staff have been trained in moving & handling, health & safety, food hygiene, fire safety and first aid. The building is clean, pleasant, warm and safe, and is well decorated and furnished. It is well maintained. There are enough staff, and the staff group is very stable, with little turnover. Residents say that the staff are always very kind, caring and hard working. Any requirements made in inspection reports are always taken seriously and are acted upon quickly. What has improved since the last inspection? What they could do better: Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 7 Fuller assessments of a new resident’s needs must be completed before that person is admitted to the home. All assessments must be fully completed, signed and dated. Every need identified in an assessment must have a care plan drawn up, to show how that need will be met. Extra care is needed in the medication records to make sure that staff always sign every time a medicine is given, and when there have been any changes to the medication records. Those staff who have not been given training in ‘safeguarding’ residents must have this arranged as a priority. 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. Carntyne Residential Care Home DS0000000601.V337967.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 Carntyne Residential Care Home DS0000000601.V337967.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): Standards 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not fully assessing all areas of possible need before admitting new residents. The home does not provide Intermediate Care. EVIDENCE: Needs Assessment: Where a potential new resident is funded by the local authority, a full assessment of need is given to the home at the time of referal. For privately funded persons, a pre-admission assessment document is used to check that the needs of potential new residents can be met. However, it is not Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 10 comprehensive enough to cover all the areas that need to be assessed. Also, one example seen was undated, so the home could not demonstrate that it had been completed before admission. The home is now considering introducing an activities of daily living-type of assessment, which is much more detailed. The home conducts a range of other assessments on or about admission. These include the Barthel and the Norton assessments, and an assessment of social needs and wishes. There is also a risk assessment., but this is not sufficiently comprehensive. Carntyne Residential Care Home DS0000000601.V337967.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): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents care plans do not properly reflect the very good care that the residents describe. The health of the residents is watched very carefully by the staff . Every residents health needs are fully assessed and met using the full range of community-based and specialist health professionals and facilities. There are clear policies and practices in place to make sure that residents are given their medication safely and at the right times, and that medicines are safely stored and administered. Recording of medicines being administered is not always rigorous enough. Residents privacy and dignity are respected by all the staff at all times. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans: This is a time of change in how the home draws up its care plans. New care plans have been introduced, with training, and some responsibility for drawing these up is now being delegated to care staff. Staff appear to be responding positively to this change. However, there need to be some improvements to current practices and formats, to make the care plan process clearer and easier for staff. Study of a range of care records showed that not all areas of assessed need are being addressed using a care plan. The format currently being used for the care plans is unacceptable because it allows a maximum of only four objectives, whereas there should be no limit on the number of plans. Also, the format being used tends to confuse the goals, interventions and monthly evaluationshas; and has no section for signing or dating the care plans. A daily care diary has been introduced, but this focusses solely on physical care, and has no cross-reference to the residents other care plans. There is an over-emphasis on physical care, generally, in the care records, at the expense of the expected holistic approach to care. All these issues were discussed with the senior in charge, and acceptable ways of improving the care records were agreed. Care plans are reviewed every month. Service users are asked to sign that they are in agreement with their care plans. Health Care: As noted above, residents health needs are taken very seriously and are regularly assessed. Staff keep a close eye on residents health and a daily record is maintained in this area. Clear and detailed records are kept of all visits to/from health professionals, and there was evidence of referal of residents for specialist treatment, where necessary. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 13 Medication: The home has a clear policy on the storage and administration of medicines. Residents will be supported in taking care off their own medicines, if they are able and wish to do so. The Medication Administration Record (MAR) was generally well-maintained, but there were some handwritten changes to doseage that were unsigned and undated. Inspection of the Controlled Drugs record book showed that several entries had only one signature, instead of the two signatures required for safety reasons. The totals of the controlled drugs were checked and found to reflect the total written in the record book. Privacy and Dignity: The majority of residents were engaged in conversation during this inspection. They all confirmed that they are treated properly by all the staff at all times. They said that their privacy is respected and their dignity upheld by the sensitive, caring approach of the staff. This was confirmed by observation during the inspection. Carntyne Residential Care Home DS0000000601.V337967.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): Standards 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents choose their own lifestyle within the home, and say that their social, religious and recreational needs are met in the home. The activities and social stimulation in the home is greatly improved since the last inspection. Residents may have visitors at any reasonable time, and are encouraged and supported in keeping links with family and friends. Residents are given support in making their own decisions, and keeping control of their lives as much as possible. Residents get a good, balanced diet, with a good degree of choice of nutritious and well-cooked meals. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 15 EVIDENCE: Social Contacts and Activities: There has been a significant improvement in the provision of social activities and other forms of social stimulation. Although it remains each rersidents choice whether or not to join in activities (and some choose never to do so), there is now a much more positive and energetic approach to this important area. One carer acts as an activities co-ordinator and has overseen a big increase in the variety and frequency of the activities being offered. The weekly set activities programme is still rather sparse and unimaginative (only the weekly exercise class and the weekly visit by the pat-a-dog service are popular), there are now more trips out, a monthly musical evening, occasional visiting entertainers and events such as clothes and cosmetics parties. An activities diary is now kept, and this shows many more events like library trips, pamper sessions, games and coffee mornings. Additionally, the staff are now carrying out social assessments of residents, to understand and, hopefully meet, their hobbies and interests, and their perfered lifestyles. These are set out in social care plans. there are also some excellent life histories and personal profiles (some drawn up by the resident his/herself, which is good practice). The home now has a much more sociable feel to it, with residents mixing more and some visiting between rooms. Residents spoke very positively about these changes, and staff are to be congratulated on the very good progress in this important area. Community Contact: The home’s policy is that residents may have visitors at any reasonable time, can see their visitors in private, and can also refuse to see a visitor, if they so wish. Staff support residents in keeping in touch with family and friends, most of whom live locally and provide good support and regular visiting. Residents may access the local community at any time, with staff support if required, and the home has its own transport available for residents’ trips out. One resident is taken to church regularly by friends. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 16 Autonomy and Choice: Residents are encouraged to be as independent as they wish, and can make their own decisions, where they have the desire and capacity to do so. this was confirmed in conversation with the residents, all of whom felt that they are actively encouraged to make choices and keep as much control of their lives as possible. Residents may control their own finances, if they are able and willing to do so. Advocacy services are available to the residents, and this service is advertised in the home. Meals: Residents spoke very highly of the meals in the home, saying they are well cooked, attractive and tasty. A new menu was just being introduced at the time of this inspection. This menu reinstated the choice of main course at the lunch meal that had been dropped at some point since the last inspection. This is welcomed as an important element of choice for the residents. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously, and responded to promptly and professionally. Residents feel confident that they can share any concerns with the staff. Policies for the safeguarding of residents have been improved since the last inspection, but not all staff have had the appropriate training in this important area. EVIDENCE: Complaints: The complaints book was studied. There has been only one complaint by a resident in the past year. This was regarding an apparent clash of personalities between a resident and a carer. It was fully investigated by the manager and recorded in good detail. Family and social worker were involved in seeking a resolution of the problem. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 18 All the residents spoken with confirmed that they feel that they can bring any concern or complaint to the attention of staff, in the knowledge that such concerns will be taken seriously and sorted out. Protection: It was a requirement of the last inspection report that the home’s policy on the safeguarding of adults must be amended to clarify that no investigation of an allegation of abuse will take place before Social Services are first alerted to the situation, and a planning meeting held. This has been carried out, and an acceptable policy submitted. Most, but not all, staff have been given appropriate training in the safeguarding of adults. This must be addressed as a priority. The manager and one other member of staff are members of a local forum on abuse, meeting every two months. There have been no allegations of abuse against any resident, and there has been no cause for any disciplinary action against any staff. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained environment. The home is clean, very pleasant and hygienic. EVIDENCE: Premises: The home was toured. It meets the residents’ needs in a comfortable and homely way. No safety hazards were found. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 20 The home is well furnished and well decorated, and there is a programme of routine maintenance. Both the first and second floor corridors have just been redecorated, re-carpetted and had new curtains hung. There are extensive gardens, which regularly win awards (1st prize in Britain in Bloom) and which are very much appreciated by the residents. Generally, the home provides a pleasant, calm and relaxed atmosphere for the residents. Hygiene and Control of Infection: The home is kept in a very clean and hygienic condition. There are no offensive odours. There are suitably located and equiped laundry facilities. The home has a policy for preventing infection and for managing any outbreak, and this has been based on Department of Health guidelines. Five staff have had training in infection control. Carntyne Residential Care Home DS0000000601.V337967.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): Standards 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the current numbers and skills mix of staff. The home has more than the required 50 of its care staff qualified to at least NVQ level 2 in care. Residents are well protected by the home’s recruitment policies, which have become more rigorous since the last inspection. The home is able to demonstrate that new staff are given the necessary induction and foundation training. EVIDENCE: Staff Complement: Staff rotas were examined. Staffing levels are being maintained at the previously agreed levels. These levels are 8am to 4pm, two carers; 4pm to 10pm, two carers plus one carer/kitchen assistant (who finishes at 8.30pm); Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 22 10pm to midnight, two carers; midnight to 6.30am, one waking night carer and one carer ‘sleeping in’; 6.30am to 8am, two carers. In addition, there are three housekeepers between 8am and 1pm; one cook from 8am to 2pm; and one kitchen assistant from 9am to 1.30pm. The manager works full time and is supernumerary to the rota. Qualifications: Eleven of the 14 carers hold National Vocational Qualification (NVQ) levels 2 or 3 in care. This exceeds the 50 required. Recruitment: It was a requirement of the last inspection report that the home must always take up at least two written references, one of which should be the job applicant’s previous employer; and that the home must amend its job application form to ensure that all applicants give a full work history, including dates. This has been carried out, and this was confirmed by study of a sample of staff personnel files. Staff Training: It was a requirement of the last inspection report that new care staff must receive formal, minuted induction and foundation training within the first six months of their employment. This has been carried out. Examples seen showed that induction was carried out over a five week period from starting employment. New staff are then put onto NVQ training, to cover their foundation training needs. Carntyne Residential Care Home DS0000000601.V337967.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): Standards 31,33,35,36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified, competent and experienced to run the home properly. The home is run in the best interests of the residents. Residents’ financial interests are protected. Staff supervision takes place at the necessary frequency. The health, safety and welfare of the residents and staff are taken seriously and are protected. Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 24 EVIDENCE: Day-today operations: The Registered Manager holds NVQ level 4 in care and management and the Registered Manager Award. She is competent and experienced in the management of the home. She is responsible only for Carntyne and works full time. She is supernumary to the rota. She undertakes periodic training to keep up to date with good practice. She has an appropriate job description and there are clear lines of accountability within the home. Quality Assurance: Quality assurance systems, based on seeking the views of residents, are in place. There is an annual user satisfaction survey, the results of which are collated and published. There has also been a staff survey, that was followed up with a stress workshop. Residents meetings are held about twice a year. Regular agenda items include menus, choice, activities, outings and any other business. Staff meetings are held approximately quarterly. The home has an annual development plan. Policies, procedures and practices are regularly reviewed. The manager takes any requirements made as a result of an inspection report very seriously and always addresses them seriously and promptly. There are no outstanding requirements from previous reports. Service Users money: Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 25 The records of cash held on behalf of residents were examined, and found to be up to date and in good order. Receipts are kept and all entries have two signatures. Spot checks on several accounts found that the cash balance matched the account totals. Staff Supervision: It was a requirement of the last inspection report that care staff must receive formal, minuted supervision at least every two months. (Outstanding requirement) This has been carried out. All care staff are now being given formal supervision every two months. Ancilliary staff receive supervision every three months. Supervision sessions are recorded in good detail. Staff are encouraged to be frank in supervision. Consideration is being given to how to meet the supervisory needs of part time staff. Safe Working Practices: It was a requirement of the last inspection report that risk assessment should be carried out on the building. This has been carried out. Accidents are routinely recorded, even where they do not result in injury. There was evidence that the manager checks all entries and records any developments or referals. The fire log book showed that there are weekly tests of fire alarms and door release mechanisms; and monthly checks of fire extinguishers and emergency lighting. Three fire drills have taken place this year. However, in-house staff training in fire safety is to be recorded more clearly. External fire safety training is being givenin the week commencing 23rd July. Carntyne Residential Care Home DS0000000601.V337967.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Carntyne Residential Care Home DS0000000601.V337967.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 Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14.1 Requirement A comprehensive assessment of all potential new residents must be carried out before they are admitted to the home. This must include a comprehensive risk assessment. All assessments must be fully completed, dated and signed. 2. OP7 15.1 A detailed care plan must be drawn up for each assessed service user need. 31/08/07 Timescale for action 31/07/07 3. OP9 13.2 All handwritten changes made by 31/07/07 staff to the Medication Administration Record (MAR) must be signed and dated. All entries in the Controlled Drugs record book must be signed by two staff members. 4. OP18 13.6 All staff must be given suitable ‘Safeguarding of Adults’ training. 30/09/07 Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carntyne Residential Care Home DS0000000601.V337967.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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