Inspection on 11/06/06 for Carr Bank House

This inspection was carried out on 11th June 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carr Bank House 12/01/10

Carr Bank House 08/12/09

Carr Bank House 22/10/09

Carr Bank House 30/06/09

Carr Bank House 17/06/08

Carr Bank House 05/07/07

Carr Bank House 31/10/05

Carr Bank House 03/07/05

Carr Bank House 18/08/04

Carr Bank House 01/04/04

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

CARE HOME ADULTS 18-65 Carr Bank House 9-11 Heywood Street Bury Lancs BL9 7EB Lead Inspector Lucy Burgess Unannounced Inspection 11th June 2006 08:00 Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carr Bank House Address 9-11 Heywood Street Bury Lancs BL9 7EB 0161 797 7130 0161 272 0133 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) Mrs Pauline Jones Mrs Jo-Ann Yvonne Simpson Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 14 service users, in the category of Adults with Mental Disorder (MD) under 65 years of age. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 31st October 2005 Date of last inspection Brief Description of the Service: Carr Bank House is a privately owned care home for 14 adults with mental health needs. Fees range from £350.00 to £460.00. This varies depending on the level of assessed need. The home is located in a residential area, close to Bury town centre, within easy reach of buses and trams, shops, cafes, and other local amenities. The house consists of 2 adjoining properties that have been adapted to form a large house. There is a small garden at the front and a large enclosed garden at the side. There are 12 single rooms and one double. Three bedrooms also have en-suite facilities. There are 2 lounges, an activities room, and a dining room. There has been an on-going programme of maintenance and redecoration, which on completion will enhance the appearance of the home. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over two days for a period of 9½ hours. The inspectors took the opportunity to look round the home, view records as well as talk with a number of residents and staff members. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for 14 people. At the time of the visit the home was fully occupied. Although the inspection was unannounced the completion of a pre-inspection questionnaire was requested, along with feedback surveys from residents, relatives and health professionals who are involved with residents. The inspector received 3 completed surveys from 2 relatives and 1 health professional. All the key standards were looked at during this inspection visits. What the service does well: Residents living at the home are very settled with some residents having lived at there for some time. Staffing has also stayed the same offering a stable place to live with staff that know the residents. Both staff and residents have developed good relationships with each other. Carr Bank is a large home that offers residents roomy accommodation in a residential area close to Bury town centre. Residents enjoy a relaxed routine and have help and support were needed. The home continues to be supported by the local mental health team. Staff have built up good working relationships with them so that residents health and well-being is maintained. Residents spoken with expressed that they were settled at the home. One resident who has recently returned to the home expressed that he ‘has the best of both worlds’, ‘privacy of own room but people around if I choose’. Another residents expressed that he ‘liked it at the home and didn’t want to move’. Staff were positive about working in the home and felt that having the office on the ground floor was more accessible to both residents and staff. Other comments included ‘it’s lovely working here’ and ‘it’s nice now, more communal’. A visiting GP commented that ‘the staff are always very helpful and on the ball’. No concerns were raised within the surveys sent by relatives. Family felt they were kept informed of their relatives well-being and were made welcome when visiting the home. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 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. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. With clear information about the assessed needs of new residents as well as opportunities for individuals to visit the home and meet residents this enables them to make an informed decision with regards to the suitability of the placement and whether needs can be met. EVIDENCE: There have been three new residents admitted to the home since the last inspection. Two of the individuals have previously resided at the home, therefore staff already had prior knowledge in relation to their background history and mental health needs. The third individual had moved from another home. Information had been provided from the social worker with regards to background information, personal details and health history. Other information also included review notes following meetings held in line with the Care Programme Approach (CPA). There was some discussion with the manager with regards to why the resident had moved having lived at the previous home with his partner for approximately 15 years. As part of the resettlement process the manager of the home had arranged a further review immediately following admissions to gather further information Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 9 around current support needs. The service user was also able to visit the home prior to admission spending time with the other residents and staff. Following this a questionnaire was completed with regards to his views and whether he was happy with the move. Through discussion with the manager, it appeared that she has and is developing a good understanding in relation to the level of support the home is able to provide to service users, ensuring that placements made are suitable and that individual needs can be met. A further admission was made on the 2nd day of inspection. The resident had moved from the other home owned by the Provider due to the placement having broke down. It had been agreed for the resident to move to Carr Bank as the manager and staff had some knowledge of his needs, behaviours, routines etc. However due to some concerns regarding his health and behaviour it had been agreed that the placement would be initially monitored and reviewed on a week-to-week basis. A review with the consultant and CPN had been arranged on the day of admission with a further meeting planned in four weeks. The manager had expressed clearly her agreement in relation to the placement whilst considering the needs of other residents living at the home. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were detailed, up to date and reflected the care needs of residents providing staff with clear information about how their needs should be met. Residents expressed they were well cared for and were involved in making decisions about their lives. EVIDENCE: Files are held for each of the residents. The inspectors looked at the files for three of the residents. Files were seen to contain care plans and risk assessments, which identified action to address identified needs, information regarding professional visits, CPNs and consultants, minutes from review meetings in line with the relevant CPA, consent agreements regarding medication and restrictions, correspondence and diary notes. Files were orderly and through discussion with staff and the manager this information was reflected within the care plans. Staff appeared to have a good understanding in relation to the needs of the residents. Through discussion Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 11 issues were identified with two residents. The manager was also aware of current issues, these were being addressed. Each of the plans seen had also been reviewed and updated on a regular basis, at least 6 monthly. The plan for the newest residents was being reviewed more frequently to ensure the suitability of the placement. Formal reviews continue to be held with mental health professionals, ensuring their health is maintained and any changes noted are then monitored. As previously identified the majority of residents are placed at the home under formal discharge programmes (CPA), which have been agreed by mental health professionals. Any concerns identified could result in residents being returned to hospital ensuring risks are minimised and individuals are protected. Residents’ preferences, likes and dislikes, were also recorded within the plans, which in the main had been signed by the residents to evidence their involvement and agreement. The home has also introduced a key worker book. This is where the resident and their key worker will discuss daily routines, activities and goals. Consideration has also been given to who has been identified as the residents’ key-worker. It was explained that this is based on effective relationships which have built up between individuals and includes night staff as they may have more opportunity to spend time with a resident due to their routine. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. This method is preferred rather than formal meetings. From feedback received and through observations made residents are relaxed and happy with the support provided and interactions with staff were seen to be open and friendly. One resident who has recently returned to the home expressed that he ‘has the best of both worlds’, ‘privacy of won room but people around if I choose’. Another residents expressed that he ‘liked it at the home and didn’t want to move’. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Routines vary depending on individual choices and preferences. Residents access the local and wider community enabling them to increase their independence. Support is offered where required. Residents maintain contact with family and friends and open visiting is encouraged. The meals are good and offer choice, providing residents with a varied diet. EVIDENCE: Each of the residents living at Carr Bank have routines based on their own choices and preferences. Whilst some individuals prefer to spend the majority of time at home, watching television, reading papers and relaxing, others follow interests away from the home. Rising and retiring times also vary depending on individual routines or motivational levels. Residents pursue activities both in and away from the home accessing the local and wider community. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 13 Some of the activities followed by residents within the community include college courses, attending Parsons Lane drop-in centre, visiting family and friends, shopping or visiting the local pub. One resident has a job in a town centre pub collecting glasses. As already identified residents have a key worker diary where their goals regarding activities or courses are identified. It is hoped that this area will be developed with support being provided by the key worker and staff in developing these areas providing residents with opportunities for further personal growth and development. The home also provides further space and privacy within the gardens. A number of residents were seen to make use of the areas. The manager explained that further furniture items and a bar-b-que were to be purchased so that residents could make more use of this area. Contact with family and friends is also encouraged. Visitors are welcome to visit Carr Bank at any time. Individuals are able to see visitors in private using the communal rooms or their bedrooms. This was seen during the inspection visits. Meals at the home are flexible. As routines vary individuals take breakfast and lunch at different times or away from the home. Meals are generally provided by staff however some individuals will provide assistance undertaking certain tasks. The home has a large kitchen, which has been provided within the recent extension and provides a good working environment. Meals provided during the visit included a cooked breakfast or alternative with the evening meal being a roast joint with fresh potatoes and vegetables. Where able residents are encouraged to develop and maintain their independent living skills. Some of the residents are involved with household tasks, including cooking, cleaning and laundry. Support is provided where required. Residents also have their own kitchen, which they use throughout the day, having access to make drinks and snacks should they wish. Provisions of tea, coffee and sugar are provided to each resident and kept in their own rooms so therefore available at any time. Two residents regular shop for their own specific food items including kosher meat. They will then cook their own evening meal once or twice a week. The home has a separate dining room where individual take their meals. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs are consistently met ensuring their well-being is maintained. Relationships with mental health professionals are effective and provide support networks for the residents ensuring their health needs are promoted. Shortfalls were noted within the medication system, these need to be addressed ensuring residents are protected and practice is safe. EVIDENCE: Each of the residents are independent and able to manage their own personal care needs however where necessary staff would offer prompts or encouragement. Residents tend to make their own decisions in relation to the daily routines. Whilst some individuals spend most of their time within the communal areas other residents prefer the privacy of their own rooms. One expressed that he had the best of both worlds and that he could spend time with others when he choose too but also had his own privacy and space. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 15 Discussions with the manager and staff indicated that they were aware of the physical and emotional needs of the residents. A staff member described how any changes in health needs, for example a change in someone’s behaviour, would be reported to the appropriate people and followed up. The medication system was examined and observation made of staff administering medication to residents. The staff member spoken with was clear about the procedure to follow. Medication was signed for on administration and given out in medication pots. Generally medication was being given at the time prescribed by the GP as stated on the MAR sheets. The staff were aware of the importance of this being done in order to ensure the health and well being of residents. Residents sign a consent to medication form that indicates whether they wish to have assistance with medication or are able to manage independently. The majority of residents are supported by staff. On examination of the Mar sheets, in the main these were up to dated and had been signed by staff on receipt of medication and when administered. A shortfall was found in relation to one resident who self medicates whilst some staff had entered SM another staff member had entered their initials. One code should be used i.e. SM, this should be stipulated on the bottom of the MAR sheets, staff should not be signing when they have not administered medication. On inspection of the stocks it was noted that medication for the forthcoming week had not been locked away securely. Other items were found which included medication purchased by one resident whilst on holiday, this was not being used so should therefore be disposed of. Other returns were needed with regards to the diabetic strips as several months’ supply was being held but not needed. One of the seniors has been identified as having the additional responsibility of managing the medication, taking responsibility for re-ordering and recording when received and returned. Weekly audits are also carried out to ensure that management of the system is safe and that staff are following procedure. The staff team have a clear understanding with regards to support made available from health professionals and will actively seek their advise and assistance where necessary ensuring the health and well-being of residents is maintained. Clear records are made with regards to health interventions. Notes are recorded following GP and Consultant visits. Records are also made when individuals have received their depot injections. Review notes in line with the CPA programme are also held on file these include reviewing the needs of residents along with their medication. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place in relation to the protection of service users as well as responding to their concerns. Policies are in place outlining the appropriate response for allegations of abuse. However training for the newest members of the team is needed in this area, to ensure that staff are aware of what action to take and the residents are protected. EVIDENCE: The home had a written complaints procedure that stated that complaints could be made directly to the CSCI. Residents said that, if they had any concerns, they would speak to a staff member, the manager or the owner. They said that they felt they would be listened to, and that they were confident that staff members would do their best to resolve the problem. In relation to adult protection, the home hold policies and procedures for staff to follow. Existing staff have also received training however this will need to be provided for those staff that have recently been appointed. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Although some work has been carried out to enhance the home further attention is still needed to ensure the health and safety of both residents and staff as well as improve the appearance of the home. EVIDENCE: As previously identified the home is situated in a residential area, close to Bury town centre and is within easy reach of buses and trams, shops, cafes, and other local amenities. The house consists of two adjoining properties that have been adapted to form one house. Work has been completed on a new extension, which provides a new kitchen, shower room, laundry and office, and two extra en-suite bedrooms. The staff office is now situated on the ground floor it is easily accessible to both staff and residents. Staff commented on how this has made tasks ie medication administration and contact with the residents much easier. Residents said that they liked living at the home. One resident expressed that he was happy to have moved to an upstairs room, whilst another resident Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 18 preferred a ground floor room, this was being arranged. The inspectors looked at one of the new rooms. These had been tastefully decorated and furnished and provided a comfortable living space for the resident, the en-suite was also well finished. Through dicussion with the manager further plans have been identified with regards to the rest of house to bring other bedrooms, bathrooms and communal areas up to the same standard. This will include both redecoration and new furniture. Action has also been identifed in relation to the external needs of the property. Progress in this area will be followed up by the inspectors. It was noted whilst walking around the home that work had started, as agreed, to the hall, stairs and landing. These were being redecorated and would later be fitted with new carpets. In the lounge areas it was found that some of the furnishings were heavily soiled and mismatched. Some areas of the room had not been cleaned as they were dusty and cobwebs had gathered. In the main kitchen, fly screens need to be fitted to open windows in line with health and safety. As stated further within the report designated staff are identified each day to undertake the cleaning. Those residents wishing to also offer help. The standard of cleanliness in most of the home was satisfactory given that work is still ongoing. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels have improved providing more opportunities to support residents as well as ensuring their health and safety. Procedure around staff recruitment have improved with the majority of checks being carried out ensuring residents are protected, minor shortfalls were noted. EVIDENCE: Staffing rotas were examined. These showed that staffing levels had increased throughout each day and evening. Daytime cover comprises of double cover between the hours of 8am and 10pm. Specific members of the team are identified to carry out the domestic tasks or cooking. In addition to this there is the Manager and Provider. Nights are covered by 1 waking staff between 10pm and 8am. An on-call facility is also available should staff need any additional support or advice. Where possible agency staff are not used as previously residents have expressed that they prefer the regular members of the team as they already know the how and the residents. From observations made and through discussions with staff it appeared that they have a good understanding of the needs and behaviours of residents. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 20 Residents have an open and friendly rapport with staff. Feedback from staff was positive about the increase in staffing as this has given them ‘more opportunity to spend time with the residents. The home has recently recruited some new staff. Information in relation to CRB checks is currently being sought. Of the files examined information included an application form, written refences, photo, copies of ID, CRB check and health declaration. Minor shortfalls were identified with regards to seeking a full employment history including an explanation of any gaps and a further written reference for 1 identified member of staff. All new staff would complete an induction. The Manager explained that this would include information being shared about the home and residents needs, policies and procedures, care plans and risk assessments. Further training would involve both formal courses as well as shadowing exisiting staff learning the role and routines within the home. This could be for a period of 2 weeks or more depending on the support needs of the staff member. In relation to staff training all but two members of the team are completing or have completed the course. The manager has also recently submitted her portfolio for the NVQ level 4/RMA. Of the staff files seen, one member of the team had undetaken an induction into mental health along with mandatory training. Additional training is undertaken by staff. Other consideration is to be given with regards to courses based on the needs of individuals being referrred to the service. A course has been planned with regards to ‘behavioural issues and drug use in mental health’ with a further courses being considered in de-esculation skills and violence in the work place. Staff were positive about working in the home and felt that having the office on the ground floor was more accessible to both residents and staff. Other comments included ‘it’s lovely working here’ and ‘it’s nice now, more communal’. A visiting GP commented that ‘the staff are always very helpful and on the ball’. No concerns were raised within the surveys sent by relatives. Family members felt they were kept informed of their relatives well-being and were made welcome when visiting the home. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements in relation to the management of the home have been developed and provide both residents and staff with structure and support. Further checks are still needed with regards to health and safety checks required within the home ensuring the safety of residents. EVIDENCE: Progress has been made with regards to the day to day management of the home. The Registered Manager has recently submitted her portfolio of evidence towards her NVQ 4/Registered Managers Award. Within her day to day role she is supported by 3 senior staff that assist in carrying out additional duties. Each have designated responsibilities within the home, which in turn is overseen and monitored by the manager. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 22 Through discussion with the manager she felt that the relationship between her and the Provider had developed providing a good working relationship, with an understanding of how the service is to be developed. The manager attempts to spend time with each of the residents so that she can check with them if they are settled, have any issues to discuss or talk to them about events that may be taking place within the home. Residents also have an identified key worker who will allocate time to spend with them to discuss their needs, goals, routines etc. This is said to be preferred than the formality of group meetings. Information is then recorded. This is an area, which has yet to be developed with the home carrying out a quality audit in relation to the service they provide. A report should be produced outlining their findings. In relation to health and safety during the previous inspection is was found that the fire door to the rear of the property did not meet the floor, with a large gap at the bottom, which would not provide any resistance in relation to fire. The manager explained that advice had been sought from the fire officer who had explained that as the door was an external door it was not essential that this was addressed. Following discussion with the manager it was agreed that written confirmation of this would be requested. It was also noted that items had also been placed at the doorway with regards to pest control. It was unclear whether these had been placed there to prevent any issues with pest or to address problems. In either case should pest (mice etc) wish to enter they would be able to do so due to the space provided at the bottom of the door. In relation to the health and safety of the environment, checks are carried out and certificates held. An outstanding requirement remains with regards to the 5 year electrical certificate, this needs to be carried out and a copy of the certificate forwarded to the CSCI. Following the two previous inspections, some records were also found to contain language that was inappropriate. For example, the fire risk assessment referred to residents being “reprimanded.” This has still not been amended. Fire records were also seen. These identified that a fault had been found to the alarm and emergency lighting. These had been addressed. Further in house checks are carried out with regards to fire safety and records are held. No incidents had occurred within the home, other than issues related to one resident whose placement had been terminated the week of the inspection. The Manager and staff had taken the relevant action to address the situation ensuring both residents and staff were safe. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 24 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. 2. Standard YA20 YA20 Regulation 13 13 Requirement The Registered person must ensure that all medication is securely held. The Registered Person must ensure that unlabelled medication is returned to the pharmacy. The Registered person must ensure that clear records are made with regards to those residents who self medicate and the relevant code stated on the MAR sheet. The Registered Person must ensure that the newest members of the team receive training in relation to the Protection of Vulnerable Adults. The Registered Person should make arrangements for fly screens to be fitted to the kitchen windows. The Registered Person must ensure that attention is given to all areas of the home identified within the refurbishment plan. The Registered Person must ensure that all staff personnel files include 2 written references and a full employment history. DS0000008422.V293239.R01.S.doc Timescale for action 31/07/06 31/07/06 3. YA20 13 31/07/06 4. YA23 18 31/08/06 5. YA24 23 31/07/06 6. YA24 23 30/11/06 7. YA34 19 31/07/06 Carr Bank House Version 5.2 Page 25 8. YA39 21, 24 9. YA42 13 10. YA42 23 The Registered Person needs to carry out a quality audit, and produce a written improvement plan. (Timescale of 28/02/06 not met) The Registered Person must ensure that an up to date check is carried out with regards to the electrical installation certificate and that a copy of the certificate is forwarded to CSCI. (Timescale of 30/11/05 and 23/2/06 not met). The Registered Person should provide information from the fire officer with regards to the safety of the identified external fire door leading to the yard. 30/09/06 31/08/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA12 YA42 Good Practice Recommendations The Registered Person should ensure that the goals identified by residents within their key worker books are explored enabling residents to grow and develop. The Registered person should forward a copy of the written advice sought from the fire officer in relation to the external door. Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Carr Bank House DS0000008422.V293239.R01.S.doc Version 5.2 Page 27 - 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. 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