Inspection on 29/11/05 for Carntyne Residential Care Home

This inspection was carried out on 29th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Carntyne Residential Care Home 14/07/08

Carntyne Residential Care Home 26/06/07

Carntyne Residential Care Home 10/05/05

Carntyne Residential Care Home 19/10/04

Carntyne Residential Care Home 29/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Carntyne Residential Care Home Hencotes Hexham Northumberland NE46 2EE Lead Inspector Alan Baxter Unannounced Inspection 29th November 2005 10:20 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.V257716.R01.S.doc Version 5.0 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.V257716.R01.S.doc Version 5.0 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 01434600195 mercy@carntyne.freeserve.co.uk 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.V257716.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 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. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of the home took place in November 2005. Time was spent with the manager, examining care records and other relevant documents. Lunch was taken with the residents. Residents were engaged in conversation. The inspection took just over five hours. What the service does well: The home treats its residents with great respect, and is very resident-centred. Residents choose how they wish to spend their day. Residents’ privacy is respected. 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. Residents get a good, balanced diet, with choice, and are very happy with the quality of the food and the cooking. Complaints are taken seriously and are looked into promptly. Residents say that they feel confident that they can share any concerns with the staff. All staff have been trained in moving & handling, health & safety, food hygiene, fire safety and first aid. There have been no allegations of misconduct by staff. The building is clean, pleasant, warm and safe, and is well decorated and furnished. There are enough staff, and residents say that the staff are kind, caring and hard working. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 3) All new residents have their needs assessed before they move into the home. EVIDENCE: 3) Study of the care records of three residents showed that all hah had an assessment of their needs carried out before they were accepted into the home. Where a local authority funds a resident, the home makes sure that a copy of the person’s care manager or social worker has supplied them with an up to date assessment of needs. Where a person is self-funding, the home conducts its own assessment. The assessment document that the home uses for this has been improved since the last inspection, and is being amended again, to further improve its effectiveness. The home now needs to introduce a system of risk assessment and manual handling assessment for each resident. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10. 7) The health, personal and social care needs of each resident are set out in his or her care plan. 10) Residents are treated respect at all times, and their right to privacy is respected. EVIDENCE: 7) It was an outstanding requirement of the last two inspection reports that a detailed and holistic care plan is needed to address all care provided to residents giving particular attention to the description of problems/needs and staff actions. This has now been largely met. Overall, care planning continues to improve, and although some plans still need to be made more detailed, others examples seen now give much clearer instructions to staff on how to meet each assessed need. Social care plans are also improving, but still need to be as individualised as possible, to reflect each residents likes, interests and hobbies. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 10 Care plans are evaluated monthly. Care should be taken to up date the care plan, if the evaluation notes any change in the person’s needs. 10) Residents spoken with said that the staff always treat them with great respect, and are kind and caring. They also confirmed that staff would always knock before entering their rooms. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. 12) Residents choose their own lifestyle within the home, and say that their social, religious and recreational needs are met in the home. 13) Residents may have visitors at any reasonable time, and are encouraged and supported in keeping links with family and friends. 14) Residents are given support in making their own decisions, and keeping control of their lives as much as possible. 15) Residents get a good, balanced diet, with a good degree of choice of wellcooked meals. EVIDENCE: 12) It was an outstanding requirement of the last two inspection reports that the home must provide a more varied and interesting activities programme, including trips outside the home, for those who wish this. This has been partly implemented, in that more activities and trips out have been offered to the residents. However, it seems to be a firmly established culture in the home that nearly all residents genuinely prefer to spend most, if not all, of their time in their own bedrooms, and are reluctant to join in organised activities. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 12 There is, however, a small group who enjoy occasional arranged activities, such as dominos,coffee mornings, gentle excercises and ‘pet therapy’ etc., and these residents said that the current level of activities suits them well. The home has recently had a Halloween evening, with appropriate decorations, food and activities, and this had proved to be better attended and more succesful than had been anticipated. The home will continue to celebrate such festivals. The Christmas season will feature visits from local Brownies, schools and church groups, and a Christmas lunch at a local church hall, with a concert at the Queen’s Hall. 13) 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. Residents may access the local community at any time (although very few chose to do so) and the home has its own transport available for residents’ trips out. 14) 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. One resident, for example, still controls her own finances. Advocacy services are available to the residents, and this service is advertised in the home. 15) Menus were studied. They show that residents are given a balanced and nutritious diet, with a good degree of choice. Residents confirmed this. Most residents take breakfast in their bedroom. A meal was taken with the residents. The meal was hot, well cooked and very tasty. It was appropriately served, with those able to serving themselves at the table, and the less able being attended to, with patience and sensitivity, by staff. Residents said that the food is nearly always very good. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. 16) Complaints are taken seriously, and responded to promptly and professionally. Residents feel confident that they can share any concerns with the staff. 18) Residents are protected from abuse by the home’s policies, and by the caring staff. However, more staff training is required in this important area. EVIDENCE: 16) The complaints book was seen. There has been only one complaint by a resident in the past year. This was regarding an alleged invasion of a resident’s privacy. It was properly investigated by the manager; was upheld; and was appropriately addressed. 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. 18) The home’s policy and procedure on the identification of, and response to, abuse was examined. It is generally a suitable model. However, there is one section that needs to 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. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 14 It was agreed that the manager would make contact with her local social services office to discus the process of reporting any allegation of abuse, and also to consider the merits of having a ‘trial run’ for reporting such allegations. Both the manager and the staff need to receive specific training in the ‘Protection of Vulnerable Adults’ (POVA). No allegations of abuse have been made within the home. No member of staff has been disciplined or dismissed. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. 19) Residents live in a safe and well-maintained environment. 26) The home is clean, very pleasant and hygienic. EVIDENCE: 19) The ground floor of the home was toured. It meets the residents’ needs in a comfortable and homely way. No safety hazards were found. There is a programme of routine maintenance. The home is well furnished and well decorated. There are extensive gardens, which have recently won a ‘Britain in Bloom’ award. 26) The home is kept in a very clean and hygienic condition, and provides a pleasant, calm and relaxed atmosphere for the residents. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. 27) Residents’ needs are being met with the current numbers and skills mix of staff. 29) Residents are generally well protected by the home’s recruitment policies, but care must be taken to always get two written references for new staff, and the job application must be amended. 30) The home was not able to demonstrate the necessary induction and foundation training is given to staff. EVIDENCE: 27) Staff rotas were examined. Staffing levels are being maintained at the previously agreed levels, despite relatively high sickness rates in recent weeks. These levels are 8am to 4pm, two carers; 4pm to 10pm, two carers plus one carer/kitchen assistant; 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. 29) The personnel files for three carers were examined. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 17 Most of the required information was on file, but one person had only one written reference. The home must ensure that at least two written references are taken up before a new staff member starts. The job application currently in use does not require an applicant to supply the dates of previous employment. It must be amended to require this information, so that any gaps in employment can be identified and queried with the applicant. 30) Staff receive induction training, but this is informal and is not recorded. It takes the form of two to three days working alongside experienced members of staff in a supernumerary position. Such training must be recorded in future. The home’s training records did not confirm that the required foundation training takes place in the first six months of employment. Staff have received the necessary training in health & safety, first aid, moving & handling, food hygiene and fire safety. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35,36,38. 35) Residents’ financial interests are protected. 36) Staff supervision takes place, but not at the necessary frequency. 38) The health, safety and welfare of the residents and staff are generally taken seriously and are protected, but a risk assessment of the building needs to be carried out. EVIDENCE: 35) The records of cash held on behalf of residents were examined, and found to be up to date and in good order. Spot checks on several accounts found that the cash balance matched the account totals. 36) It has been an outstanding requirement from the last two inspection reports that all care staff must receive supervision at least every two months. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 19 This has been partly addressed. Most staff have received supervision three times in the past year (the required frequency is every two months for care staff). This has been partly due to higher than average staff sickness in recent weeks and months. A part-time deputy manager has recently been employed and she will assist the manager in providing formal supervision at the necessary frequency. 38) The fire logbook was up to date, with all the required checks and tests of systems and equipment, and fire instruction and drills being carried regularly. The accident book was also well maintained and up to date, with all entries countersigned by the manager. The service agreements for gas, electrical equipment, bath aids etc. are in place. A risk assessment of the building must be carried out. Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 20 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 3 8 X 9 X 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 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 2 X 2 Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP18 Regulation 13.6 Requirement The home’s policy on the protection of vulnerable 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. The home must always take up at least two written references, one of which should be the job applicant’s previous employer. The home must amend its job application form to ensure that all applicants give a full work history, including dates. Care staff must receive formal, minuted supervision at least every two months. (Outstanding requirement) A risk assessment should be carried out on the building. New care staff must receive formal, minuted induction and foundation training within the first six months of their employment. Timescale for action 30/11/05 2. OP29 19.1 30/11/05 3. OP36 18.2 31/12/05 4 4 OP38 OP30 23.2 19.5 31/01/06 31/12/05 Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 22 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.V257716.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carntyne Residential Care Home DS0000000601.V257716.R01.S.doc Version 5.0 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!