Inspection on 03/07/05 for Carr Bank House

This inspection was carried out on 3rd July 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

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 11/06/06

Carr Bank House 31/10/05

Carr Bank House 18/08/04

Carr Bank House 01/04/04

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Alfred House Residential Care Home

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Fernhaven

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Creative Support

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 Sue Evans Unannounced 3 5 & 13th July 2005 rd th 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 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 Stationary 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 F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 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 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 Simpson CRH PC - Care Home Only 12 Category(ies) of MD (Mental disorder under 65 years of age) registration, with number of places CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Within the maximum registered number 12, there can be up to 12 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. The Registered Manager must complete the Registered Managers Award and undertake periodic training and development to maintain and update her knowledge, skills and competence. Date of last inspection 18th August 2004 Brief Description of the Service: Carr Bank House is a privately owned care home for 12 adults with mental health needs. 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 1 house. There is a small garden at the front and an enclosed garden at the side. All bedrooms except one are single. There are 2 lounges, an activities room, and a dining room. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors over 3 days for a period of 13¼ hours each. On the first day, a Sunday, inspectors visited unannounced at 7.45am and spent 6 hours in the home. More than half of this time was spent watching what went on in the home, talking to 6 residents, and interviewing 2 staff members, one of whom was a member of the night staff. During the second day, the inspectors spent 5 hours in the home, interviewing the Registered Manager and examining records. The CSCI Pharmacist Inspector also visited to look at the home’s medication procedures. Her findings were sent to the home in a separate letter. The letter is available, on request, to members of the public. On the third day inspectors spent 2¼ hours looking round parts of the building with the Fire Safety Officer, and talking to the Registered Manager and the owner’s husband. Following the previous inspection in August 2004, an additional visit was made to the home (in January 2005) when checks were done to see whether the home had met the requirements that had been made. The Pharmacist Inspector also visited the home on 31st March 2005 to look closely at the home’s medication procedures. Since the last inspection, Mrs Jo-Ann Simpson has been approved by the CSCI as Registered Manager of the home. What the service does well: Residents said that Carr Bank had been a good choice of home, and that they were satisfied with the help they received from staff. One resident said, “Staff treat me well. They help me”. Staff members were knowledgeable about the needs of the residents and they spoke with, and about, residents in a respectful, caring way. The manager has helped residents to register with an independent advocacy group so that they can, if they want to, ask someone who does not work in the home to support them. This can help them to have more choice and control over their lives. Residents and staff feel that the manager is approachable, and supportive, and they are comfortable about airing their views, or making requests. During the inspection, two residents confidently approached inspectors to object to the use of the term “service users” in inspection reports. They said that they preferred “residents.” CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 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. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1 and 2 The Statement of Purpose and Service Users’ Guide contain useful information about the home. However, some additions are needed to the Service Users’ Guide so that prospective residents have enough information to help them decide whether they would like to live in the home. Residents are included in agreeing their identified needs, giving them a say in what they need help with. EVIDENCE: The Statement of Purpose and Service Users’ Guide contained useful information about the home including details of its facilities, the experience and qualifications of the staff, and a copy of the complaints procedure. The Statement of Purpose contained all the necessary information. However, the Service Users’ Guide still needed a few additions in order to provide prospective residents with full information about what to expect from the home. These additions included a copy of the terms and conditions of residence, details of where a copy of the most recent inspection report could be found, and a brief summary of the purpose of the home. Records showed that care management assessments had been carried out for residents before they came to live in the home. The Manager was asked to store care management assessments in residents’ personal files so that they were easily accessible. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 10 The Manager said that compatibility with the existing resident group would be considered before anyone was admitted to the home. Assessment information showed that residents had been included in agreeing their support needs. The residents who were spoken with said that Carr Bank had been a good choice of home. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 6, 7 and 9 Some care plans and risk assessments do not fully reflect the residents’ changing needs. They need expanding so that they provide detailed guidance to assist staff in providing the support that is necessary. Residents are able to make decisions about their lifestyles, with support and guidance from staff if needed, enabling them to exercise their right to autonomy and individuality. EVIDENCE: Since the last inspection, the Manager had introduced a new, improved format for writing care plans and risk assessments which made it easier to pick out key information. Records showed that residents had signed their agreement to their care plan. Residents’ preferences, and likes and dislikes, were recorded. Staff members were asked about the needs of three of the residents. They were consistent in their descriptions of each person’s needs, and how they helped and supported them. This matched with the information given by the residents. However, care plans did not fully reflect the support being given by CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 12 staff. Staff clearly had a wider knowledge of residents’ needs than was recorded in care plans. For example, one care plan did not include details about how the resident would be supported to handle racist remarks from another resident. In another case, crucial information from the care management contingency plans had not been transferred to the home’s own care plan. Care plans should be developed from the initial agreed assessment of needs. It was noted that the care management records were stored in box files, and not in the residents’ personal files. The up to date care management records need to be stored in personal files where staff can easily find them. Risk assessments were in place. However, these also needed reviewing to ensure that they contained full information about identified risk, and how the risk was to be reduced to a minimum. On the first day of the inspection, the personal file of one resident was not available for inspection. The Manager said that she had been updating it and had inadvertently locked it away in her desk drawer. Residents’ files must be available at all times so that staff members are able to refer to them if necessary. Information about independent advocacy was displayed in the home. The Manager said that all residents had registered with the “Care Aware” Advocacy Service. This gives residents the opportunity, if they wish, to ask someone who does not work in the home to support them. This can help them to have more choice and control over their lives. Residents confirmed that they were able to make their own decisions about their lives. Where assistance was needed, for example with money management, the agreed support was recorded in personal files. During the inspection, staff members spoke with residents in a natural, friendly way. All the residents who were spoken with during the inspection said that they were satisfied with the support provided. One resident said, “Staff treat me well. They help me”. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 11, 12, 13 and 14 Residents are part of the local community and they choose how they spend their time, taking part in activities that they enjoy. However, present staffing levels mean that they have limited opportunities to pursue fulfilling activities during evenings and weekends. EVIDENCE: Residents followed their own daily routines. They said they were satisfied with their lifestyles and could choose how they spent their time. Most residents were able to take part in community activities without staff support. During the inspection, some of them were seen coming and going from the home independently. They gave examples of the community facilities that they used such as public transport, cafes, pubs, and shops. One resident was undertaking a computer course at Bury College with a view to eventually finding a job. Another was doing a woodwork course, and undertaking independent living sessions with an Occupational Therapist. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 14 Records showed that organised activities were offered during weekdays. These activities included swimming, baking, visits to a flea market, gardening, and games. Some residents were looking forward to a trip to Blackpool that had been arranged for the following week. At home, residents enjoyed pastimes such as watching television, listening to music or doing crosswords. Whilst efforts were being made during weekdays to encourage residents to participate in meaningful, fulfilling activities, staffing levels during evenings and weekends did not allow for this. This is covered further under the “Staffing” section of this report. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 20 Staff training for those who administer medication, together with detailed procedures, helps to promote residents’ health and safety. However, there is a need for extra storage so that new deliveries of medicines are not left out where unauthorised people might be able to access them. EVIDENCE: On the second day of the inspection, the Pharmacist Inspector visited the home to look at medication procedures. Full details of her findings were contained in a letter that was sent to the home. The letter will not be published but it will be made available, on request, to members of the public or other enquirers. The home’s medication policies and procedures had been recently reviewed and expanded, and now included the handling of non-prescribed medicines. None of the residents looked after their own medication, except for occasions when one resident was away from the home and needed to take his medication with him. A recommendation was made with regard to expanding the resident’s self-administration assessment to include some further details in respect of medication taken out of the home. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 16 There were records of medication received, administered, and disposed of. However, there were some discrepancies in the recordings on the medication record sheets, and a requirement has been made in respect of this. A new delivery of medication had been left out on the office windowsill because staff did not have room to store it in the existing lockable cabinet and they did not have access to the keys to a locked storage cupboard. A requirement was made in respect of the provision of suitable storage space. Residents had signed a “Consent to Medication” form. These forms need to be stored in a place accessible to the senior person on duty. Staff members had been trained in the safe handling of medicines. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 23 Protection policies, and staff training in adult protection, ensure that the service has the means to be able to respond properly to any suspicion or allegation of abuse. EVIDENCE: The home had written procedures covering adult protection and whistle blowing. Staff members had received training in the protection of vulnerable adults. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 18 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 standard(s) 24, 25, 26, 27, 28, 29, and 30 Improvements made since the last inspection have resulted in a nicer environment more suited to the needs of the residents. However, in order to further improve the environment for residents, and to ensure the health and safety of both residents and staff, the home needs to attend to several items of work. EVIDENCE: The home is situated 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 two adjoining properties that have been adapted to form one house. Work has been taking place for some time on the building of an extension to provide new kitchen, laundry and office facilities, and two extra en-suite bedrooms. Since the last inspection, the dining room has been fully refurbished and it now has French windows opening onto an enclosed garden at the side. One resident said that she was pleased with these improvements and loved to sit outside when the weather was warm. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 19 The home has three other communal rooms that have also been improved since the last inspection. These are the non-smoking lounge, the smoking lounge, and the activity room. The home has two bathrooms and a shower room. The shower room has been fitted with a walk-in shower. Residents said that they were satisfied with their rooms. They had brought in some of their own possessions to make their rooms more homely. Most areas of the home were looked at. Several items of work needed doing, including some relating to fire safety. By the time of the Fire Safety Officer’s visit on the third day of the inspection, some of the work had already been completed. The work needing attention is included under the requirements section of this report. It includes attention to weeds and litter at the front of the house, attention to cracked and broken windows, attention to some décor and furnishings, the deep cleaning of the stairs carpets, and a number of fire safety requirements. Standards of cleanliness in the home were satisfactory. However, although liquid soap and paper towels were provided for hand washing in most areas, they were not provided in the small ground floor toilet. In the interests of promoting good hygiene, this needs to be addressed. There is also a need to replace the cistern cover in this toilet. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 The numbers of care staff on duty during weekdays after 5pm, and all day at weekends, are insufficient to meet the needs of the residents. The required pre-employment checks are carried out in order to protect residents. Staff members are trained in the mandatory topics to provide them with the knowledge and skills that they need to meet the health and safety needs of the residents. EVIDENCE: The rota showed that, at weekends, and after 5pm on weekdays, there was only one member of staff on duty. Weekend staff are responsible for cooking and cleaning, and this allows little time for any in-depth, meaningful work with residents. Discussions, observations, and examination of personal files showed that a number of residents had high levels of support needs. (In order to ensure confidentiality for residents, examples are not given in this report, but have been recorded separately). Although another staff member is on-call at all times, there are nevertheless risks attached to lone working, particularly when some residents have a history of challenging behaviours, including physical aggression and self-harm. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 21 Several days midnight in a one resident. highlights the before the 3rd inspection visit, a fire was started at around resident’s room. The lone worker managed to evacuate all but Whilst this resident thankfully came to no harm, this incident potential risks of lone working. The owner must ensure that the home is adequately staffed at all times in order to ensure the health and safety of both residents and staff. The varying needs of the current resident group would point to the need for there being at least 2 staff members on duty at all times. Rotas did not include full names and were not always amended to show the actual hours a person had worked. They need to be accurately and fully completed to show dates, full names, and actual hours worked. During the last inspection, a requirement was made for the home’s staff recruitment checks to include health declarations, and recent photographs. This had been done. The home had obtained new induction booklets for use with future recruits. Staff training records showed that staff members were routinely trained in topics such as fire safety, medication, food hygiene, first aid, and health and safety. Training in Adult Protection had just taken place. The manager said that domestic staff, as well as care staff, had attended the Adult Protection training. The manager had identified those staff members who needed updated training in specific topics. Courses planned for the near future included Health and safety and COSHH (Control of Substances Hazardous to Health) on 15/7/05, first aid on 12/7/05, food hygiene on 18/7/05. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41 and 42 Residents benefit from the open management approach of the home and they are able to openly express their wishes and opinions. In order to safeguard residents’ rights, care needs to be taken in the language used in records to ensure that they are relevant, factual, and objective. There are several health and safety matters needing attention which compromises the health, safety and welfare of residents and staff. EVIDENCE: The manager has been registered with the CSCI since June 2005. She is undertaking the Registered Manager’s Award. Residents and staff said that she was approachable and supportive. Records showed that regular staff meetings and residents meetings were held so that people could air their views. It was observed that residents were quite confident about approaching the manager and staff, either to seek information, request something, or express opinions. During the inspection, two residents confidently approached CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 23 inspectors to object to the use of the term “service users” in inspection reports as opposed to their preferred term “residents” A number of records were found to contain language that was inappropriate. For example, the fire risk assessment referred to residents being “reprimanded.” The minutes of a staff meeting (that were undated) gave the impression that, once the residents kitchen was in use, only a set amount of tea and coffee would be supplied, and residents who failed to keep he kitchen clean would be “banned” from it. The Manager said that the wording was misleading and that this had not been the intention. Further inappropriate recordings were found on daily report sheets. These recordings should be relevant, factual and objective, and should relate back to agreed care plans and risk assessments. However, there was evidence to show that the Manager had picked up on some of the inappropriate recordings and brought them to the attention of staff members. Several safety records were checked. These included fire alarms and emergency lighting servicing, fire extinguisher servicing, and portable electric appliance testing. The electrical installation certificate did not specify the expiry date. The manager was asked to obtain written information about this from the engineer. Several health and safety matters were brought to the attention of the Manager. In order to reduce the risk of fire, some doors needed to be fitted with door closures, smoke seals, and intumescent strips, some doors needed attention so that they closed fully to the rebate, the bedding store needed to be kept locked, the new kitchen needed a heat detector, and there was a need to close the roof void hatch in one resident’s bedroom. In addition, the home’s evacuation procedures and fire risk assessment needed amending. The waste basket in the smoking lounge needed to be replaced by a metal one and must not be lined with a plastic liner. The Health and Safety Officer visited the home on 26/5/05 and made a number of requirements. These must be dealt with. CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 2 2 x x x Standard No 31 32 33 34 35 36 Score x x 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 CARR BANK HOUSE Score x x x 2 Standard No 37 38 39 40 41 42 43 Score x 3 x x 2 2 x F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 25 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 5 Requirement The Service Users Guide needs some minor additions. (Timescale of 31 October 2004 not met) Some care plans need expanding to reflect all areas of need. They need to be developed from the agreed assessment of need. The Registered Person needs to ensure that staffing levels, particularly at weekend, are sufficient to allow staff members to support residents in meaningful activities both inside and outside the home. The Registered Person must address the requirements set out in the Pharmacist Inspectors report in respect of medication storage, and the keeping of accurate, up to date medication records. Weeds and litter need to be removed from the front of the house. The cracked window pane in the 1st identified bedroom must be replaced. The broken window in the new extension needs to be relaced, or temporarily boarded up. Timescale for action 30 September 2005 30 September 2005 31 October 2005 2. 6 15 3. 13, 14, 33 16(2)(m) (n) 18(1)(a) 4. 20 13(2) As advised by the Pharmacist Inspector 5. 6. 7. 24 24, 26 24 23(2)(o) 23(2)(b) 23(2)(b) 31 August 2005 31 August 2005 19 August 2005 Page 26 CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 8. 9. 24 24, 26 23(2)(d) 16(2)(c) 10. 11. 24,26 24 16(2)(c) 23(2)(d) 12. 30 16(2)(j) 13. 33 18(1)(a) 14. 33 17 The stairs carpets need deep cleaning. The following items of work must be carried out to the 2nd identified bedroom: Attention to the wardrobe doors to ensure that they close properly. Replacement of the mattress. Re-varnishing of the drawer unit Attention to the ill-fitting lightshade. Attention to the floor boards, in the corner of the room, that have become detached from the floor. The wardrobe door in the 3rd identified bedroom needs to be replaced. The following items of work need to be finished: The painting of the ceiling in the no-smoking lounge. Attention to the peeling wallpaper in the smoking lounge Attention to the corner ceiling tiles in the level access shower room. Paper towels and liquid soap must be provided for hand washing in the small ground floor toilet. The cistern cover in this toilet also needs replacing. The Registered Person must review staffing levels with a view to ensuring that residents and staff are not placed at risk because of lone working. The Registered Person must provide the CSCI with full written details, by the date in the end column, of how those staffing levels have been decided upon, and what risk factors have been taken into account. Staff rotas must include full names and they must show the 31 August 2005 30 Sept 2005 30 Sept 2005 30 Sept 2005 19 August 2005 30 August 2005 5 August 2005 Page 27 CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 15. 41 17, 6 16. 42 13(4) 17. 42 23(4) 18. 42 23(4)(c) (v) actual hours worked by each staff member. Written records must be relevant, factual, and objective. The records listed under Schedule 3 of the Care Homes Regulations 2001 must be available for inspection. The most recent Care Management Assessments need to be stored in personal files where they can easily be accessed. The Registered Person needs to obtain written information showing the expiry date of the electrical installation certificate. The Registered Person must provide the CSCI with written information detailing the action taken to address the fire safety matters identified by the Fire Safety Officer on 13/7/05. These were: The fitting of self closing devices to 4 specified doors. The inclusion of smoke seals and intumescent strips to each of the 4 door sets. Ensuring that the side panelling to the staircase between the basement and ground floor is of 30 minutes fire resisting standard. The securing of the roof void hatch cover in an identified bedroom. Investigation into the provision of additional fire detection equipment in respect of one residents bedroom. Amendments to the Fire Risk Assessment. Amendments to the Fire Evacuation Procedures. The home must ensure that metal bins are provided in areas where smoking takes place, and 5 August 2005 19 August 2005 19 August 2005 3 July 2005 CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 28 19. 20. 42 42 23(4) 13(4) that the bins are not lined with plastic bags. The bedding storeroom must be kept locked. The Registered Person must provide the CSCI with written details of the action taken to address the requirements made by the Health and Safety Officer during the visit of 26/5/05 3 July 2005 19 August 2005 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 Good Practice Recommendations CARR BANK HOUSE F56 F06 S8422 Carr Bank House V215539 030705 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich, Bolton BL9 7EB 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. 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