Inspection on 31/10/05 for Carr Bank House

This inspection was carried out on 31st October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 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 11/06/06

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 Sue Evans Unannounced Inspection 31st October 2005 09:20 Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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.V259740.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V259740.R01.S.doc Version 5.0 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 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. 3rd July 2005 Date of last inspection 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 DS0000008422.V259740.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by 2 inspectors over 1 day for a period of 6¼ hours each. Some of this time was spent watching what went on in the home, talking to 6 residents and interviewing 2 staff members. The inspectors also looked round some of the building, examined some key records, and interviewed the manager and owner. This inspection was the second to take place in the current inspection year. In order to gain a fuller picture of the home, this report needs to be read in conjunction with the report of the previous inspection of July 2005. What the service does well: What has improved since the last inspection? What they could do better: There are a number of items of work needed to ensure a pleasant, safe environment for residents. Some of these are outstanding requirements from the last inspection and the owner must make sure that she takes prompt steps to deal with them. Pre-employment checks for staff need to be more thorough so that residents are not put at risk. Also, the numbers of staff on duty need to be enough to ensure the safety of residents and staff, and to support residents to take part in meaningful activities both inside and outside the home. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 6 There is a need for the home to check out peoples’ opinions on the quality of the service, and to produce a written plan that will show residents, and others, how their views are being used to improve the service. One resident’s care plan and risk assessment needs to be updated to reflect his changing needs so that staff have up to date guidance to help them to provide the support the resident needs. Some other records also need improving. Residents gave their own suggestions for improvements to the service, and these included more staffing, more organised outings, and the provision of Sky TV and a computer. 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.V259740.R01.S.doc Version 5.0 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.V259740.R01.S.doc Version 5.0 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): 1 The Statement of Purpose and Service Users’ Guide contain useful information about the home. They give prospective residents information that can help them decide whether the home is suitable. EVIDENCE: Standards 1 and 2 were assessed in July 2005. At the time of the last inspection, the Statement of Purpose contained all the necessary information. It was therefore not looked at this time. The Service Users’ Guide had been updated and it contained useful information about the home including details of its facilities, the experience and qualifications of the manager and staff, and details of the complaints procedure. A poster, informing people where they could find copies of CSCI inspection reports, was displayed prominently in the hallway of the home. The owner was reminded to include a copy of the terms and conditions of residence when supplying people with copies of the Guide. This will ensure that they have all the relevant information. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 9 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 and 9 Residents are included in reviewing their needs and know that, following reviews, the written information about them (care plan and risk assessment) is updated. They were less clear about their right to see this information. One person’s care plan and risk assessment needed updating to reflect his recently changed needs. EVIDENCE: Standards 6, 7 and 9 were assessed in July 2005. The personal files of two of the residents were looked at. They contained care plans and risk assessments. One resident’s needs had recently changed but his care plan and risk assessment had yet to be updated to reflect the changes. The owner said that a formal planned review was to be held for this person within the very near future. The personal records of a fairly new resident showed that the home had developed its own care plan from the initial agreed assessment of needs. Staff members were asked about the needs of the two residents referred to above. They were consistent in their descriptions of each person’s current support needs. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 10 Residents’ preferences, and likes and dislikes, were recorded, and they had signed their agreement to their care plan. Residents knew that, following reviews of their support needs, care plans and risk assessments were updated in line with any changes. However, some residents seemed unsure about their rights to see this written information if they wanted to. The owner and manager were therefore advised to make sure residents were fully aware of this right. It was clear from discussions and written records that the home consulted with other health and social care professionals when the need arose. As requested at the time of the last inspection, care management records were being kept in the residents’ personal files where staff could easily find them. The residents who were spoken with during the inspection said that they were happy with the support provided. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 11 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): 13, 14, 15, 16 and 17 Residents are able to travel outside the home independently and they choose how they spend their time. However, they said they would like to get out more on organised outings, but present staffing levels mean that opportunities for staff to support them in fulfilling activities, particularly during evenings and weekends, are limited. Contact with families and friends is supported. Practices in the home respect residents’ rights to privacy and choice. The menus offer choice and variety, and provide residents with a diet that they enjoy. EVIDENCE: Standards 11, 12, 13 and 14 were assessed in July 2005. Residents were very independent and were able to go out without being accompanied by staff. During the inspection, some of them were seen coming and going from the home independently. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 12 When asked about the kind of activities they took part in, some residents said that they spent most of their time at home, either with other residents in communal areas of the home, or in the privacy of their own rooms. They said they mainly watched TV, or listened to music, or sat chatting. They did say that they would like to be able to use the computer, and they would like Sky TV to be installed in the home. These suggestions were passed on to the owner who said that she would look into them. One person said that he liked to go to Bury town centre most days, and another said he sometimes had a walk to the local Asda. Staff members said that one resident had a voluntary job with a local charity. Residents said that they would like to get out more on organised outings to places such as the cinema, ten-pin bowling, leisure centres (for tennis or swimming), and trips out to shows or to Blackpool. Staff members said that they regularly put forward ideas for outings but residents tended not to show much interest. Even so, as stated in the last inspection report, whilst it might be possible during weekday afternoons, to encourage residents to participate in meaningful, fulfilling activities, staffing levels during evenings and weekends did not allow for this. A staff member said that residents were encouraged to keep in touch with their families and friends. She said that visitors sometimes stayed for meals. Residents gave examples of how they kept in contact with family and friends. A friend of one of the residents was visiting the home during the inspection. The owner gave examples of how residents were supported with their friendships. She was also mindful of the risk of people entering into relationships where one person was more vulnerable than the other. Residents said that they could choose how they spent their time. Most residents said that they did very little for themselves when it came to household tasks such as cooking, washing up, and looking after their own rooms. They said that staff mostly carried out those tasks. However, one resident said that an Occupational Therapist was helping him to improve his cooking and housework skills. Staff members said that they did try to encourage residents to keep their rooms tidy and to make their own beds, but without much success. Residents were satisfied that their privacy was respected, for example nobody entered their bedrooms without knocking. Locks were fitted to bedroom doors, and residents had a key. They said that mail was given to them unopened. Residents said that staff treated them with respect. Staff members gave examples of how residents’ choices and rights were promoted in the home. They also gave an example of how they tried to dissuade residents from pursuing activities that posed a risk to themselves and others. Residents were satisfied with the meals provided. always a choice of dishes. They said that there was Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 13 There was a planned 4 week rotating menu. It included various dishes including roast dinners, pasta dishes, and snack meals. The owner said that menus were changed regularly in line with residents’ wishes. In addition to the 3 main meals, suppers were also available, and it was observed that residents had hot and cold drinks throughout the day. Staff members confirmed that they had done food hygiene training. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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 Most residents attend to their own personal needs, with prompt and encouragement if needed. Any changes in health needs are dealt with in liaison with the appropriate specialist health services. Medication procedures and storage promote the health and safety of residents. EVIDENCE: Standard 20 was assessed in July 2005. In respect of personal needs, most residents were very independent and able to manage for themselves. Staff said that sometimes prompt and encouragement was needed. However, they said that one resident felt safer if staff helped him in the shower. Residents said that they had choices about their daily routines, for example what time they got up. On the day of the inspection, some of the residents were still in bed, having a lie in, when the inspectors arrived at 9. 20 am. Residents said that they were satisfied with the way that the owner and staff treated them, and the way they spoke with them. During the inspection, it was observed that staff members spoke with residents in a natural way. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 15 Details of all contacts with health professionals were recorded. Records showed that the home requested assistance from specialist health workers if necessary. Discussions with the owner 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. The pharmacy inspector had visited the home as part of the last inspection to look at medication procedures. Since then the home had made arrangements for more secure storage of medication. None of the residents looked after their own medication. Residents had signed a “Consent to Medication” form. Medication was securely stored. There were records of medication received and administered. The records included details of medication taken out of the home, for example if a resident went out for the day. Quantities of medication received were entered onto the medication record sheets. The owner was asked to make sure that the staff member who entered this information onto the sheet, signed their initials against it. A staff member said that a weekly medication audit was carried out. However, records showed that audit records were only kept if there were any discrepancies. It was recommended that a record be kept of all audits, whether there are discrepancies or not. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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 Residents feel that any concerns would be listened to and dealt with. EVIDENCE: Standard 23 was assessed in July 2005. 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. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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, 26, 27, 28 and 30 Further improvements made since the last inspection mean a nicer environment for the residents. However, the home still needs to attend to several items of work in order to ensure the health and safety of both residents and staff. EVIDENCE: Standards 24, 25, 26, 27, 28, 29 and 30 were assessed in July 2005. 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 a new kitchen, shower room, laundry and office, and two extra en-suite bedrooms. Residents said that they were satisfied with their rooms. Since the last inspection, the home had completely refurbished one resident’s bedroom and this represented a big improvement. Other rooms had also benefitted from Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 18 new furniture or redecoration. However, in one room the bedding was very worn and needed replacing. The home had met some of the requirements made at the time of the last inspection. These were: attention to cracked and broken windows, attention to some décor and furnishings, and a number of fire safety requirements. However, some requirements had not been met. These were: attention to weeds and litter at the front of the house, the painting of the ceiling in the nosmoking lounge, attention to the peeling wallpaper in the smoking lounge, attention to the corner ceiling tiles in the level access shower room, the fitting of a cistern cover in the small ground floor toilet, and the inclusion of smoke seals and intumescent strips to each of the 4 specified door sets. It was also noted that a plastic waste bin had again been placed in the smoking lounge despite a requirement that only metal bins were to be used in smoking areas. This was rectified immediately but the owner was asked to remind all staff members that metal bins must be used. The stairs carpet was still in need of deep cleaning, but workmen were using these stairs to reach the extension and it was impossible to maintain a satisfactory level of cleanliness. The owner said that, when the extension was completed, the stairs and landing would be redecorated and re-carpeted. Standards of cleanliness in most of the home were satisfactory given that building work was ongoing. As required during the last inspection, liquid soap and paper towels were being provided for hand washing in the small ground floor toilet (as well as in other communal areas). Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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): 33 and 34 The numbers of care staff on duty during weekdays after 5pm, and all day at weekends, are insufficient to ensure the health and safety of residents and staff, or to allow staff members to support residents in a meaningful way. Failure to carry out all the required pre-employment checks on staff can put residents at risk. EVIDENCE: Standards 33, 34 and 35 were assessed in July 2005. As stated in the last inspection report, the staff rota showed that, at weekends, and after 5pm on weekdays, there was normally only one member of staff on duty. Even though there are on-call arrangements in place, these staffing levels could compromise the safety of residents and staff if an emergency arose. Weekend care staff are also responsible for cooking and cleaning, and this allows little time for any in-depth, meaningful work with residents. Since the last inspection, two residents with high support needs had moved out of the home. However, discussions, observations, and examination of records showed that another resident’s changing needs were giving cause for concern. The owner and staff said that extra staff cover had been brought in to cover particularly difficult periods. Nevertheless, there are risks attached to lone working, particularly when unexpected events occur. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 20 As stated in the last report, it is the responsibility of the registered person to 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 resident group point to the need for there being at least 2 staff members on duty at all times. Indeed, residents themselves said that they would like an extra staff member to be on duty at weekends. As required during the last inspection, staff rotas now included full names. However, they had not always been amended to reflect absences and the actual hours a person had worked. They need to be accurately completed to show actual hours worked. Staff recruitment records were looked at. The records for a new recruit contained proof of identity and a medical fitness declaration. However, the CRB (Criminal Records Bureau) disclosure certificate had been obtained during the person’s previous employment. The owner was unaware that CRB checks were no longer portable. She was asked to arrange for a new CRB check, including a POVA (Protection of Vulnerable Adults) List check. Also, although there were 2 written references on file, one of them had not been received until after the person took up their duties. The manager said that she had obtained a verbal reference and, due to staffing shortages, had allowed the person to start. She was advised that, under no circumstances must a new employee be allowed to start work before two written references have been received. On checking the person’s employment record, it was noted that there was a gap of 2 years unaccounted for. This needs to be investigated. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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, 41 and 42 Residents benefit from the approachability of the manager. The home needs to carry out a quality survey, and produce a written improvement plan that will show residents and others how their views are being used to improve the service. In order to safeguard residents’ rights, some recordings need improving to ensure that the wording is appropriate, and that written reports are meaningful and relevant. To ensure that the health and safety of residents and staff is fully promoted, a number of health and safety matters need attention. EVIDENCE: Standards 38, 41 and 42 were assessed in July 2005. The manager has been registered with the CSCI since June 2005. She is undertaking the Registered Manager’s Award. Since her appointment she has Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 22 made improvements in some areas, for example the format for writing care plans and risk assessments. Staff members said that the manager and owner were approachable, and it was observed that residents and staff had no hesitation in approaching them if they wanted to speak to them. The home needs to carry out its annual quality audit, which must include the use of anonymous satisfaction questionnaires, and seek the views of residents, staff, regular visitors, and health and social care professionals. The outcomes need to be collated into a brief report with an action plan showing areas for improvement. A copy of the improvement plan needs to be made available to residents, and others, so that they know that their views have been noted and, where applicable, acted upon. A copy also needs to be sent to the CSCI. At the time of the last inspection, some records were found to contain language that was inappropriate. For example, the fire risk assessment referred to residents being “reprimanded.” This had not yet been amended. The samples of daily report sheets that were looked at had improved slightly in that they did not contain any inappropriate language. However, discussion took place about the need to ensure that entries are meaningful and relate back to agreed care plans and risk assessments. There was also a need to make sure that information held in residents’ personal files included the date. Most safety records were checked during the last inspection. This time, fire records were checked and found to be up to date. The fire alarms and emergency lighting had been serviced on 11/10/05 and found to be satisfactory. As identified during the last inspection, the electrical installation certificate did not specify the expiry date. The manager said that she had received verbal confirmation that a re-test was not required until 5 years had elapsed. She was asked to obtain this in writing. Other health and safety matters needing attention included the fitting of smoke seals, and intumescent strips on some door sets, and the need to ensure that waste baskets in the smoking areas were metal (not plastic) and that they were not lined with a plastic liner. It was also noted that a key pad had been fitted to the door at the top of the stairs leading down to the office. Residents said that sometimes, when they tried to attract the attention of the staff member by knocking on the door, the staff member didn’t always hear them. This could pose a risk if an emergency arose, especially with the lone working taking place evenings and weekends. The home therefore needs to fit a bell or alarm so that staff can be alerted quickly. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 2 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carr Bank House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X 2 2 X DS0000008422.V259740.R01.S.doc Version 5.0 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. Timescale for action YA9YA6 14, 15 The care plan and risk 30/11/05 assessment for one identified resident need updating to reflect his changing needs. YA33YA14YA13 16(2)(m)(n) The Registered Person needs 31/12/05 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. (Timescale of 31/10/05 not met) YA20 13(2) The registered person needs 31/10/05 to make sure that staff members who write the quantities received on the medication administration records (MAR), initial at the side. YA24 23(2)(o) Weeds and litter need to be 30/11/05 removed from the front of the house. (Timescale of 31/8/05 not met) YA24 23(2)(d) The ceiling in the no- 31/12/05 smoking lounge needs DS0000008422.V259740.R01.S.doc Version 5.0 Page 25 Standard Regulation Requirement 2. 3. 4. 5. Carr Bank House 6. YA24 23(2)(d) 7. YA24 23(2)(d) 8. 9. YA26 YA30 16(2)(c) 23(2) 10. YA33 18(1)(a) 11. YA33 17 12. YA34 19 painting. (Timescale of 30/9/05 not met) Attention is needed to the peeling wallpaper in the smoking lounge. (Timescale of 30/9/05 not met) Attention is needed to the corner ceiling tiles in the level access shower room. (Timescale of 30/9/05 not met) The worn bedding in the identified bedroom needs replacing. A cistern cover needs to be fitted in the small ground floor toilet. (Timescale of 19/8/05 not met) The registered person must ensure that residents and staff are not placed at risk because of lone working. The registered person is requested to furnish the CSCI with a brief written summary of each residents’ needs, and details of the risk factors taken into account when determining staffing levels. Planned staff rotas must be amended, as necessary, to reflect the actual days and times that the owner, manager and staff have worked. (Timescale of 5/8/05 not met) The registered person must ensure that a robust system of pre-employment checks in carried out. This includes: 1. Obtaining 2 written references. 2. Exploring gaps in DS0000008422.V259740.R01.S.doc 31/12/05 31/12/05 30/11/05 30/11/05 30/11/05 31/10/05 25/11/05 Carr Bank House Version 5.0 Page 26 employment. 3. Applying for a CRB and POVA check whether or not the person had a check done with a previous employer. The registered person must inform the CSCI in writing, by the date in the end column, of the steps taken to address the above matters. The home needs to carry out a quality audit, and produce a written improvement plan. Written records must be dated, must contain appropriate wording, and must be meaningful and factual. (Timescale of 5/8/05 not met) The registered person must obtain written information showing the expiry date of the electrical installation certificate. (Timescale of 19/8/05 mot met) The registered person must arrange for smoke seals and intumescent strips to be fitted to the 4 identified door sets. The home must ensure that metal bins are provided in areas where smoking takes place, and ensure that the bins are not lined with plastic bags. (Timescale of 3/7/05 not met) The registered person needs to fit an alarm or bell to the door at the top of the stairs leading to the office. 13. 14. YA39 YA41 21, 24 17 28/02/06 30/11/05 15. YA42 13(4) 30/11/05 16. YA42 23(4) 30/11/05 17. YA42 23(4) 31/10/05 18. YA42 13(4) 30/11/05 Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 27 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. 3. Refer to Standard YA6 YA14Y YA20 Good Practice Recommendations The registered person is advised to make sure that residents know about their rights to see their personal records. Given the comments made by residents, the registered person is asked to look into the provision of a computer, and Sky TV for the benefit of residents. The registered person is advised to complete the weekly medication audit record, whether or not there are discrepancies. Carr Bank House DS0000008422.V259740.R01.S.doc Version 5.0 Page 28 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.V259740.R01.S.doc Version 5.0 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. 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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