Inspection on 30/03/07 for Carpenter Place

This inspection was carried out on 30th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Carpenter Place 14/02/06

Carpenter Place 06/10/05

Carpenter Place 29/09/04

Carpenter Place 18/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Carpenter Place 103 Oldfield Road Sparkbrook Birmingham West Midlands B12 8TN Lead Inspector Jill Brown Key Unannounced Inspection 30th March 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 Carpenter Place DS0000016741.V334924.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. Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carpenter Place Address 103 Oldfield Road Sparkbrook Birmingham West Midlands B12 8TN 0121 440 2823 0121 440 2520 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) Moseley & District Housing Association Samantha Adele Price Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That Samantha Price successfully undertakes the Registered Managers Award or equivalent by June 2006. The home may accommodate up to 5 service users who fall between the ages of 55 and 65 who require care for reasons of physical disability. (5PD) 14th February 2006 Date of last inspection Brief Description of the Service: Carpenter Place is a large two storey, purpose built residential facility providing bedroom, lounge, fitted kitchen and bathroom. There are four flatlets that can accommodate two people. Service users are encouraged to personalise their own flatlets with their belongings. Furniture is provided for those requiring it. Flatlets are furnished to meet the needs of the service users and are decorated as required. Service users can choose to take meals on a full board or part board basis. They can prepare their own breakfast and teas in their flatlets if they wish. There are some respite facilities available. Communal facilities consist of lounge, dining room, hairdressing salon, bathing/showering facilities, laundry, main kitchen and small shop. There is ample parking to the front of the building and very pleasant enclosed gardens to the rear with lawns, shrubs and seating for the service users. The fees for April 2006 to March 2007 were £346 per week. Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited the home on a day in March and carried out an unannounced inspection where most of the standards were looked at. The inspectors arrived at 09.30 and stayed for the majority of the day. Prior to the inspection information was collected from contacts with and about the home since the last inspection, a pre-inspection questionnaire the home was asked to complete and the return of 3 comment cards from residents and 1 from a GP surgery. During the inspection the inspectors spoke with 6 residents and one relative and observed the interactions between staff and residents. A tour of the shared areas of the building was undertaken and a number of residents’ flats were seen. The inspectors looked at a lot of records including two resident care files in depth and a further three in depth, three staff personnel files and the accident records. The inspectors looked at medication records and checked some these against some stocks of residents’ medication. Three residents’ personal money held by the home was checked against the records the home kept. This information forms the basis of the report. What the service does well: Residents at the home were happy about the care they received and thought that they talk to the manager and other staff in the home about their concerns. Residents thought they had enough information top help them choose the home and had contracts stating the terms and conditions of their stay. Residents could had been able to visit the home as many times as they wanted before making a decision to stay. Residents health was monitored and records showed that if there was any concern residents were referred for specialist help like district nurses, GP, falls clinics, and so on. Residents talked about their good relationship with the manager saying ‘I like Sam she makes me laugh.’ A relative said the staff were ‘golden.’ Residents appeared to be helped to maintain their independence and plans were in place to assist only in the areas that residents needed help. Residents were seen to walk around the home at will, some spending time in the reception area or Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 6 lounges others walking the corridors and others remaining in their flats or going out. There were meetings arranged to discuss residents their views and at these meeting group activities were discussed. All the residents spoken to thought that the food was good, there was arrangements made for food to meet cultural and health needs. The building’s layout supports those residents that want to maintain their independence and there are assisted bathing and showering facilities for those residents that need help in this area. The home maintains training of staff and the majority of staff have achieved at least an NVQ2 in care as well as training in food hygiene health and safety and so on. This ensured that residents have staff that know how to provide care well. The home has good systems in place to monitor the care provided, and supervise the staff. The manager of the home has the qualifications and experience to ensure the home is run to the benefit of the residents. What has improved since the last inspection? What they could do better: The home needed to ensure that some areas of assessing residents’ needs, care planning and risk assessment were more detailed. For example the home needed to be sure they had enough information about a residents communication needs to instruct staff how best to communicate with them. They needed also to ensure they were aware of the full difficulties residents had in moving and transferring so that the instructions to staff in care plan had the type of hoist needed and the size of sling so resident receive consistent help. This is important when Agency staff and new staff are working in the home. Whilst the home offered a range of group activities they needed to ensure residents that find it difficult to join groups have one to one time with staff or individual activities to prevent them feeling lonely. The home didn’t have available the details of investigations undertaken by a representative of Moseley and District Churches and this must be available for inspectors to assure themselves that the proper process ahs been undertaken. The inspectors found information however that supported the manager’s verbal report. Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 7 The home had areas that needed some maintenance and decoration. The homes audit of this was not always the same as what the inspectors found. The home needed to ensure that they have a list of work that needed doing and dates when this would be achieved. The Commission have asked for a copy of this. The home needed to ensure that the restrictors on the showers were working and that staff were told to report if they didn’t. The environment could be improved to ensure the safety and comfort of residents. Staffing levels were generally satisfactory however on occasions mainly at the weekend staffing levels were lower and the inspectors noted that Agency staff had to be used to maintain adequate staffing levels. 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. Carpenter Place DS0000016741.V334924.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 Carpenter Place DS0000016741.V334924.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): 2, 3 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides enough information for residents to choose whether this home will suit their needs. Residents have the opportunity to visit and experience the home several times before making a choice. Residents’ rights are protected by a contract. This means that placements are more likely to be successful. Whilst assessments are undertaken in key areas more detail in some areas would make planning more effective to meet residents’ needs. EVIDENCE: The home makes arrangements for residents to receive information about the home and be made aware of the terms and conditions for their stay. Each resident is issued with a contract/licence agreement. A copy of this is kept for each resident, together with Social Services Assessment information, Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 10 the funding agreement, and a personal inventory. Comment cards from residents said ‘ I do not know if I got a contract but I got a lot of information’ ‘I chose the flat that I have in the home.’ All three comment cards suggested that residents had enough information to make a choice about the home. Assessments undertaken by social workers were in place for two residents although a care plan from the social worker was only available on one of the two care files checked. Details from the assessment needed to be more detailed. In one care file there was information that a resident had some difficulty in communicating but could express their needs. The resident’s first language was not English and the home had not identified on the file the resident’s first language. The assessment did not identify if the difficulty in communication was because of language or a health condition. The home also did collect clear information about dietary requirements for an insulin dependent diabetic. This lack of detail makes it difficult for the home to plan the care to be provided appropriately. It was clear where necessary potential residents had the opportunity to visit the home on several occasions before deciding that this was the place for them. One resident visited for lunch and again before they permanently moved to the home and this means that residents are more aware of the service the home can provide. Carpenter Place DS0000016741.V334924.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. The home ensured that residents have detailed care plans further improvements in some areas would ensure that all of the residents needs are met consistently. The home had good systems to identify and to refer health needs to the appropriate professionals and this ensured that residents’ health was maintained. The home has good, safe systems of medication administration and this helped to ensure residents health was maintained. The home has facilities and attitudes that maintain the privacy and dignity of residents. EVIDENCE: Residents care plans could be improved to ensure they meet all of the resident’s needs. Each resident had a support plan these covered the main areas of care needed. A summary of care was also provided as a quick Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 12 reference tool for staff to refer to and this was good practice. A number of care plans needed further information on how to deliver the care so that residents’ needs could be fully met. One resident’s care file did not detail the diet sufficiently to ensure that the residents religious and medical needs were accounted for and this could lead to the resident having poor and unsuitable nutrition. One resident had no information about mouth care or details of the shared care with relatives and this was important to ensure that care was always given. One resident with a mental health concern did not have enough information about how the individual displayed that their mental health was deteriorating. Care plans were set out in a clear orderly way that allowed information to be retrieved easily. Care plans detailed items such as domestic chores that residents needed help with within their flats; this either maintained the resident’s independence or ensured that these tasks were undertaken. The home was not always reviewing care plans on a monthly basis. Residents had risk assessments for areas of perceived risk and these were updated on a 6 monthly basis or sooner if needed. Risk assessments were seen for potential for the development of pressure areas, moving and handling, poor nutrition, smoking and so on. A number of risk assessments needed more detailed descriptions on how the risk was to be minimised to ensure the safety of the resident. For example a resident that smoked had a minimal smoking risk assessment that requested that staff visited the flat on a half hourly basis but did not assess fully the ability of the resident to smoke safely. This meant that the measures the home had put in place were not effective to minimise the risk. Moving and handling assessments did not always have the level of detail needed to ensure residents were moved correctly such as ‘ proper use is made of moving and handling equipment.’ This description doesn’t mention sling sizes or type of hoist to be used. The home ensures residents’ health needs were met. The home records well any accidents or falls and these are reported to the Commission. The home arranges for residents that fall to see their GP and there was evidence of residents attending falls clinic where necessary to try and prevent recurrences. Residents were weighed where possible however where this is not possible another measure such as circumference of upper arm may be useful. The home were not recording in detail what residents were eating and how much and this was area that needed improvement so as to ensure that residents have appropriate amounts of food. The home showed that they worked well with District Nurses and other health professionals to ensure the well being of residents. One resident’s skin being maintained in a good state despite the high level of risk of the resident having pressure areas. There was evidence of visits from GPs, District nurses, chiropodist, dentists and opticians when needed. A comment card from a GP surgery stated that the home was ‘conscientious and caring,’ ‘cooperative and had good communication.’ Residents comment cards felt that their medical Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 13 needs were met. Residents of this home have key workers one residents comment card said that their key worker was ‘very nice.’ The home manages residents’ medication well. Medication was stored securely in the home. Five residents medication administration records were looked at and the following found. All medication was administered as directed. The home undertakes medicine audits on a daily basis so any errors can be corrected. Sampled counts of medication were found to be correct. One medication needed to be referred to the GP for instructions on use to be clear on the medication, one medication had been discontinued but this was not evident on the Medication Administration Record although it had not been administered and one medication had not been dated when opened. These were minor issues. Residents spoken to were happy with the care they receive. Residents appeared to be dressed in individual styles reflecting their choice. Residents have access to a private telephone room if they want to have calls, a number of residents have telephones in their flats. Residents have individual flats and this ensures that personal care is given privately. Residents that were assisted to have baths said this was done well. Carpenter Place DS0000016741.V334924.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. The home needed to look at residents that do not join group activities to ensure that individual activities or one to one time was given so that these residents do not become isolated. The arrangements for residents to have visitors were good and this enhances residents’ lives. There were no undue restrictions on residents’ movement and choices in their day-to-day life. This means residents feel in control. The arrangements for food respected residents’ needs and allowed them to maintain some independence. EVIDENCE: The home provided group activities for residents but activities are not individually organised for residents that do not join these. Residents were involved in activities but a number of comment cards suggested that this could be improved, others stated that they preferred to remain in their flat watching the television. On the day of the inspection a number of residents were Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 15 involved in making Easter parade hats and there was a pantomime planned on the early evening for residents to attend. A resident went out using a ring and ride service as the inspectors arrived. There were signs of activity equipment as a large Connect Four game, craft materials and a large television. The home had a list of formal activities that were available in April. A resident had a social care plan that stated, ‘arrange social interaction at least once a month’ without having any details of the resident’s interests and a resident’s comment card stated that they were not helped to do painting by numbers which was their particular interest. The home had resident meetings and activities were on this list to discuss. The home has a church service for those that wish to attend. On occasions staffing levels had not been sufficient for an organised activity to take place. Relatives appeared to be encouraged to be involved in the care of their relative. One relative spoken to was very happy with the care their relative received. There appeared to be no undue restrictions on relatives being allowed to visit. Residents have private flats where they can see visitors or there several quiet areas throughout the home. Residents were able to move around the building at will. One resident said ‘I have no restrictions about going out.’ A number of residents liked to sit in the reception area, walk around the building, or sit in the lounges; others preferred to stay in their flats. Residents flats looked at showed that residents were able to bring in their personal belongings. Residents were happy with the food provided. Comments from residents were ‘He is a very good cook,’ ‘ food is good’ and two comment cards spoke of how the chef cooks good meals. Residents choose a meal from a menu list before the food is prepared. Residents can choose to make their own breakfast and or teas if they are able or have these supplied for them. The home supplied the Commission with menus of food. In addition to traditionally English food the home supplied a Caribbean menu. The home had a resident who was not from either of these cultures and the home negotiated with the family how appropriate food was to be supplied before the resident was admitted. The home had plenty of food available on the day of the inspection. Carpenter Place DS0000016741.V334924.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. Whilst the home did not have the details of investigations on site the verbal report of the manager, other records and reports from residents showed that concerns were dealt with appropriately. Residents were able to voice their concerns. Information on abuse and adult protection was available to staff and residents and this protects residents. EVIDENCE: The home records complaints when they arise. Formal complaints are investigated by the home provider Moseley and District Churches. On the day of the inspection the details of the investigation of these complaints were not available for inspection. The manager about the outcome of these investigations gave a verbal report. The home had received two complaints, were not reported to the Commission. The home was able to demonstrate where staff performance was an issue that this was identified and action had been taken. The home does take complaints seriously and listen and act when concerns are raised. Complaint forms were available in reception as were inspection reports, newsletters from the Commission and leaflets about stopping abuse of older people. Comment cards from residents said ‘I speak to ‘Sam’ (the manager) and another named staff member if we are unhappy. We have forms Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 17 to make complaints on.’ ‘I’d speak to Sam or another named staff member. I can complain there is a form.’ ‘I would speak to another named staff member if I’m unhappy. Residents spoken to said ‘I would go to the office but there is nothing wrong’ and ‘I’d go to Sam I like Sam she makes me laugh.’ Residents spoken to say they felt safe in the home. Almost all of the care staff have had recent training in the protection of vulnerable adults. Carpenter Place DS0000016741.V334924.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, 25 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the building layout is appropriate for residents needs some improvement was needed to maintenance and infection control to ensure that the home remained a pleasant and safe environment for the residents. EVIDENCE: Each resident has his/her own self-contained flatlet within the home, and in addition has access to communal areas on the ground floor and first floor. The home was generally clean and free from odour however there were some areas that needed attention. The home has systems in place to monitor daily the cleanliness of flats and to look at items that needed repair. However this was not always a true reflection of issues that needed addressing. (See Standard 33) One flat looked at had problems with the toilet that had been an issue for some time causing bad staining, another flat had an odour, there were areas of the home that needed Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 19 decoration and one ventilation fan needed a longer pull cord to make it easier to use. The inspectors accept that in maintaining the residents rights to be independent the cleanliness of flats may vary. The inspectors were informed that two areas where curtaining would be an improvement that this was in hand. Some corridors and communal toilets décor were beginning to look tired and lacked pictures. The home had good storage facilities for large pieces of equipment such as hoists and platform scales and this means that the home can maintain a very homely feel. Whilst the home has assisted bathing facilities of varying types to meet the needs of residents the inspectors were concerned that the showers thermostats were not effective allowing water to get too hot. Both inspectors and the manager tried two assisted showers. A resident said of the showers ‘they are never too cool but staff try it out on their hands and adjust it and they adjust it if you tell them its too hot.’ The home needed to do some further checks on infection control, in the kitchen the freezers were not maintained at below –18 degrees centigrade and mops were not stored appropriately on all occasions and a substance that may be hazardous to health were found in an unlocked cupboard. A resident commented that the home was ‘a clean place if I have an accident they come straight away.’ Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The home had not always been able to maintain a sufficient number of staff on duty and this had affected services such as activities. The home plans to have a stable staff group but agency staff were sometimes needed which leads to some resident dissatisfaction. The majority of care staff have had the basic training of NVQ level 2 and this means residents have staff that are aware of their care needs. Some improvements were needed in the Staff records to ensure a clear employment record as this protects residents. Staff were trained in the areas needed to provide good care to residents. EVIDENCE: Staffing has been difficult at the home with staff leaving and two staff posts were being advertised. Agency staff were covering staffing shortfalls. In an eight-week period the home had on average over 66 hours of agency staff cover in a week. On the day of the inspection 6 care staff were on the early shift of which 2 were from an agency. The manager, housekeeping and catering staff, were in addition to these staff. Residents commented that ‘some agency staff do not listen’ ‘I prefer our own staff.’ Staffing rotas showed that Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 21 on occasions staffing had been low especially on Saturdays. A resident said that sometimes staffing was low. Residents commented that usually staff were available but accepted that sometimes they had to wait. The home met the standard to have 50 of staff qualified to NVQ level 2 in care. Three staff files were looked at and the inspectors found that the quality of information kept on file about recruitment varied. One file did not have an application form. The inspectors were informed that this was held centrally, and they would ensure that a copy was sent down to the home. All files had copies of references, identity checks and checks with the Criminal Records Bureau. Staff had an induction programme and for the first two weeks worked with another member staff extra to the staffing rota this is good practice and ensured the safety of residents. However one staff file did not have an induction programme. Staff had risk assessments completed where necessary. Staff files did not contain always contain reasons for non-attendance at supervision and this does not give an accurate employment record. Staff files did not always contain copies of certificates of attendance on mandatory courses. The home had a matrix of staff that had attended courses and this showed that the majority of staff had attended the majority of courses such as fire, health and safety, food hygiene and so on. A large number of staff were to attend moving and handling courses at the beginning of April. In addition a number of staff had completed courses in falls awareness and welfare benefits. These additional courses ensure that staff were well trained to meet the needs of residents. Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the benefit of an experienced and qualified manager and systems in place to ensure the quality of the service provided for residents. Residents’ money was managed in a safe way where this was necessary and the home ensured they were aware of residents’ financial arrangements. The management team supervised staff regularly and this means that the standard of service could be maintained. The health and welfare of service users was maintained by good record keeping and attention to inspections and maintenance of key services. EVIDENCE: Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 23 The home has a qualified and experienced manager to run the home. Residents thought they could talk to the manager, the GP surgery, staff and a relative spoken to thought the home was well run. The home has a quality assurance system that takes the views of residents into account. It includes audits of the service and issues of the home. The inspector looked at the environmental audit (see standard 19) and judged that this needed to be done less often but more thoroughly. The audits of falls and accidents were good (See standard 8). The home has resident and staff meetings routinely. The home assists residents manage their personal allowance in ways appropriate to their needs. Three residents money was checked against the records and receipts and in all cases this was correct. The home has the benefit of being able to use a credit union bank and this means residents can access money by a visiting bank. The home on admission checks with relatives how personal monies are managed and by whom. On one file it was noted that a relative had been appointed as power of attorney. The home helps relatives manage their relative’s money by keeping a small float of money for toiletries hairdressing and so on where appropriate. Staff files showed that staff were given formal supervision on a regular monthly basis and this exceeds the target set by the standard of 6 times a year and this is commended. The home had a well-organised system of records that enhance the care of residents for example daily records for residents. Daily records for residents were completed several times a day and contained good notes about visits by medical professionals, which allowed the tracking of any health concerns. The home had evidence of the maintenance and servicing of fire safety, gas and electrical safety. The requirements made by the fire officers’ visit in November 2006 have been completed except for ensuring all residents’ flats must have letter boxes that form a seal when closed in case of fire but this was in hand. The home had appropriate maintenance and testing of the lifting equipment used by the home. Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 24 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 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 4 3 3 Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1)(a) Requirement The Registered Person must ensure where a need is identified an assessment of that need is carried out. The Registered Person must ensure that all areas of identified need have clear steps of how the need is to be met including: Oral care Shared care with relatives Religious and dietary needs. Information about the individual’s relapse triggers on residents with mental health issues. The Registered must ensure that risk assessments and steps to minimise risk are in sufficient detail including risk assessments for Moving and handling to include type of equipment to be used and how, Residents that smoke. Care plans must be reviewed on a monthly basis as to whether they are adequately meeting the needs and minimising the risks to residents. DS0000016741.V334924.R01.S.doc Timescale for action 31/05/07 2. OP7 15(1) 31/05/07 3 OP7 13(4)(c) 31/05/07 4 OP7 15(2) 31/05/07 Carpenter Place Version 5.2 Page 26 5 OP12 15(1), 16 (2)(n) 22(8) 6 OP16 7 OP19 23(2)(b) (d) 8. OP22 23(2)(n) 9 OP25 13(4)(c) 10 11 OP26 OP26 13(3) 13(3) The Registered Person must be able to show that all residents’ social activity needs have been assessed and met. The Registered Provider must ensure that copies of all investigations be available for inspection. The Registered Person must ensure that a thorough inspection is undertaken of the environment and an action plan made for deficiencies found. A copy of this must be sent to the Commission. The Registered Person must ensure that an assessment of the individual needs of residents for aids and adaptations is carried out, and any requirements arising from this made available to residents. Not inspected on this occasion All assisted bathing and shower facilities must be appropriately regulated to ensure that water is provided to close to 43 degrees centigrade. All kitchen freezers must be maintained at a temperature below –18 degrees centigrade. The Registered Person must ensure that substances that may be hazardous to health are securely stored. Timescale 14/02/06 not met. 30/06/07 31/05/07 31/05/07 30/06/07 30/04/07 30/04/07 30/04/07 12 OP27 18(1)(a) 13 OP29 19 The home must ensure that cleaning mops are appropriately stored. The Registered Person must 31/05/07 continue with plans to ensure a stable staff group and must ensure that a consistent level of staff to meet the needs of residents is available at all times. The Registered Person must 31/05/07 ensure that all staff files contain DS0000016741.V334924.R01.S.doc Version 5.2 Page 27 Carpenter Place 14 OP33 24 the information to demonstrate induction, qualifications and the recruitment process. The Registered Person must ensure that audits are a true reflection of the situation or practice. 31/05/07 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 OP8 Good Practice Recommendations It is recommended that the Registered Person use another measure other weight to determine the effectiveness of nutrition for residents that cannot be or that refuse to be weighed. It is recommended that the Registered person devise a system of recording what residents have eaten during the day. The Registered Person should continue to monitor the use of agency staff, with particular regard to the views of residents. This recommendation remained outstanding. 2. OP27 Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Carpenter Place DS0000016741.V334924.R01.S.doc Version 5.2 Page 29 - 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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