Inspection on 05/07/07 for Carr Bank House

This inspection was carried out on 5th July 2007.

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 11 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 11/06/06

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 5th July 2007 09:30 Carr Bank House DS0000008422.V340770.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.V340770.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.V340770.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 763 1747 jocarrbank@aol.com 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.V340770.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. 11th June 2006 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.V340770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home, carried out by 2 inspectors over 1 day. An initial visit was made to the home, however due the Manager being on maternity leave and the Deputy Manager was day off the inspectors arranged to visit later in the week to meet with the Manager. The inspectors were advised that the Manager was working some hours in order to gradually return to work. Whilst the Manager has been on leave the home has been supported by the Deputy Manager, who is new to the post with further support from the Registered Manager for the ‘sister’ home, Laburnum House and the Registered Provider. As part of the inspection process the Manager was asked to complete an Annual Quality Assurance Assessment (AQAA). The was done and forwarded to the CSCI. Information provided was detailed and looked at both the strengths and weaknesses of the home and how the Manager wished to develop and improve the service provided. During the visit inspectors spent time talking with residents, speaking with staff and the Manager as well as looking at records. Sometime was also spent looking round the home at what improvements had been made to the environment. All the key standards were looked at during the inspection. What the service does well: Residents living at the home have lived there for some time. Whilst minor changes have taken place within the staff team a number of staff have been at the home for some time and have a good understanding of residents needs. This provides a stable environment for the people living at the home. Carr Bank is a large home that offers comfortable accommodation for residents. The home is in a residential area close to Bury town centre. Residents enjoy varied lifestyles based on their own preferences and have help and support were needed. The home continues to be supported by the local mental health team. Residents have access to either a social worker or a CPN and a psychiatrist to support them with their mental health needs. Staff have built up good working relationships with them so that residents health and well-being is maintained. Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Visits made by the Registered Provider must be developed so that information clearly evidences that residents’ benefit from a service, which has a sound quality assurance system and self-monitoring process. The Registered Provider has yet to undertake a review of the quality of care provided by the home ensuring that feedback from residents, their families, stakeholders etc is being considered by means of quality assurance and make ongoing improvements to the service. That CSCI must be informed that the work identified on the electric certificate has been carried out to ensure the health and safety of residents. Detailed records with regards to water temperatures also need to be improved so that information evidences that checks carried out and any action taken where necessary. Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 7 Information collated when recruiting new staff should clearly evidence the process undertaken. Documents should be clearly dated so that the information can be clearly audited ensuring practice followed is safe. A updated training skills audit of the whole staff team must be undertaken to ensure that they have received all the necessary training relevant to their roles and responsibilities and that evidences residents are in safe hands with staff that are competent to carry out their role safely. Updated assessments care plans and the risk assessments need to be provided for all new residents ensuring that changing needs are reflected and staff care clear about the support that is to be provided ensuring residents and safe and protected. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Without clear and up to date information about the assessed needs of new residents an informed decision can not be made about the suitability of the placement and whether needs can be met. EVIDENCE: As identified on previous inspections, appropriate action has been taken to ensure that information about the assessed needs of individuals is gathered prior to them moving into the home. During this site visit the Inspectors were aware that one of the residents now living at Carr Bank on a short term basis had moved from Laburnum House, the ‘sister’ home, due to behavioural issues, which they felt they were unable to manage. Information was examined with regards to this resident due to the issue that had arisen and how they were now being managed. It was noted that none of the information had been updated or reviewed since October 2006. In the absence of the Manager, who is currently on maternity leave, the person responsible for arranging the placement at the home must ensure that the relevant assessment information is reviewed to determine suitability of the placement and that the concerns previously identified do not impact on those people already living at the home. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are in place for each of the residents and in the main reflect their needs. However were new placements are made at the home information must be kept under review so that staff are provided with the information required to meet current needs safely. EVIDENCE: Individual files are in place for each of the residents. Records held include a care plan, risk assessment, personal information, professional visits, CPA minutes and daily diaries. Risk assessments were also in place on the care records, which had been completed by the CPN. Records were examined for several residents and were generally found to be in good order and up to date. However one of the files looked at was for a resident identified in standard 2, who had recently moved into the home from the ‘sister’ home. In the absence of the Manager, the care plan and risk assessment for this resident had not been reviewed and updated. This Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 11 information is required because the discharge from the other home was due to behavioural issues, which were impacting on other residents. The inspectors were informed that this placement was only on a short-term basis. However the resident expressed that she would be returning to the home and had requested this and preferred living at the other home. It was unclear what discussion had been held with the resident and if the move back to the home had been clearly explained as the resident expressed that the move would be soon. Whilst this may be an option, the inspectors were concerned that the move from the original placement was due to behaviour, which they were not able to manage. This was aggravated by resident’s mental state and facilities available within the home. Whilst it is acknowledge that this is something the home is planning to address this will not be for a number of months and therefore may result in a re-occurrence of previous behaviours. Residents have a key worker diary. This was initially devised to record their achieved goals and where other areas of support can be provided. The Manager explained that these have not been used as effectively as they could have been and is exploring how better they can be used providing residents with opportunities for further personal growth and development. The Manager and staff continue to spend time with each of the residents so that they 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. This is said to be preferred than the formality of group meetings. Information is then recorded. Residents’ preferences, likes and dislikes, are also recorded within the plans, and individuals are encouraged to signed to evidence their involvement and agreement. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports and provides opportunities for residents to maintain appropriate and fulfilling lifestyles both in and away from the home. EVIDENCE: Residents follow a lifestyle of their choosing both in and away from the home. Whilst some of the time is spent watching television, reading papers and relaxing, others times include more planned activities away from the home accessing the local and wider community. Some of the activities followed by residents within the community include college courses, cookery classes, gardening, visiting the local pub, shopping and visiting friends and family stay for meals or overnight where possible at the home, the home is also going to set up a computer for residents and explore internet access. Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 13 One resident continues to have a small job in a town centre pub collecting glasses and another attends college courses. One resident has an outside support worker who visits the home each week and supports the resident in doing a planned activity away from the home. This is to assist the resident in developing their confidence as well as their independent living skills. The home also provides further space and privacy within the gardens. One resident in particular enjoys the privacy of the garden and spend a lot of time relaxing there. Residents continue to be encouraged to maintain contact with family and friends both in and away from the home. 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. The partner of resident also stays over night occasionally. Meals at the home are flexible. This is dependent on what residents are doing. Lunch was observed during the visit. A homemade vegetable soup had been made with fresh hotpot and red cabbage for tea. Alternative options are available. The home has a large kitchen, which was provided when the home was extended and provides a good working environment. Residents also have access to their own kitchen were they are able to make drinks and snacks when they choose. Some residents regularly do their own shopping buying specific food items including kosher meat. They will occasionally cook their own evening meals during the week. The home has a separate dining room where individual take their meals. As previously identified, 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. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear monitoring and support is provided in supporting resident to maintain their health and well-being. Medication is managed safely and effectively. EVIDENCE: Residents living at Carr Bank are independent and able to manage their own personal care needs however where necessary staff would offer prompts or encouragement. Discussions with the Manager and staff indicated that they were aware of the physical and emotional needs of the residents. Clear records continue to be made with regards to health interventions. Notes are recorded following GP and Consultant visits. Review notes in line with the CPA programme are also held on file these include reviewing the needs of residents along with their medication. The majority of residents are supported by a small group of mental health professionals and have good links with the home offering support and advice. One resident receives outreach support, which involves 1-2-1 support to assist Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 15 in developing life skills. Through discussion with the manager and deputy manager it was clearly demonstrated that issues involving certain individuals had been looked at and staff had been providing support in such a way that issues and concerns had been minimised. This involved monitoring and checks carried out within the home as well as more formal intervention with medication changes. Another resident was said to be concerning staffing staff due to changes in behaviour, this too was being closely monitored and staff were liaising with the psychiatrist. A further resident who had moved into the home prior to the last inspection was said to have settled and it was felt that generally the residents mental health was stable however physically they were unsure. Staff were exploring ways of promoting his physically well being including offering a variety of vegetarian meal options. The medication system was examined. A safe system of medication management was found. Items are stored safely and well organised. The Deputy Manager takes responsibility for the ordering and monitoring of all medication. 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. Residents have previously signed 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. Some individual do self-medicate when going away over night, information is recorded and arrangements are made for items to be taken securely. On examination of the MAR sheets, these were up to dated and had been signed by staff on receipt of medication and when administered. The Deputy Manager explained that improvements had been made in this area and that she was closely monitoring where gaps had been left on the sheets. The Deputy Manager evidence to the inspectors the checks, which had been carried out and explained that action, had been discussed with the Manager about how to address the matter with the relevant staff. Records are also held with regards to medication, which is returned to the supplying pharmacy. The Deputy Manager is also exploring a more in-depth medication course around the needs of the service, which will increase her knowledge and understanding around the medication prescribed to residents. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place with regards to the complaints and adult protection issues. Relevant training has been undertaken by all members of the team ensuring residents are safe and protected. EVIDENCE: The home had a written complaints procedure that stated that complaints could be made directly to the CSCI. Residents appear to have good relationships with staff and feel able to speak openly with each other. Two residents spoken with also expressed that they able to speak with members of the team about any concerns they may have. Residents have previously expressed that they feel 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. All staff have received training in adult protection and copies of certificates are held on file. Following a previous issue the manager contacted the relevant authorities to clarify roles and responsibilities should a further issue arise ensuring the safety and protection of the residents. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Carr Bank provides comfortable, homely accommodation for the residents. On-going redecoration and refurbishment is taking place to improve the appearance of the home. EVIDENCE: Carr Bank 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. Accommodation comprises of several communal lounges/sitting areas, dining room, 2 kitchens, laundry and several bath/shower rooms. Three of the bedrooms also have en-suite faciltities. Office space is also provided on the ground and lower ground floors, providing suitable space for the manager and staff to work. Work has recently been completed to the front of the property with a new external wall being built and gates being fitted. These have improved the appearance of the home. Other work inside the home has also involved Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 18 redecoration of the smoking lounge, completion of the decorating and new carpeting to the hall and stairs and several bedrooms have been repainted and new furniture purchased. Whilst looking round the home it was found that 2 windows were broken and in need of replacing. The inspectors were advised that replacement glass had been ordered. There was also damp to the gable end of the property, several bricks appeared loose on the chimney and the gable wall and roof were not sealed causing water to soak into the walls. The Manager confirmed that there had been on-going issues regarding damp in the room directly below. Further damp was seen in the sitting area adjoining the dining room, this was thought to be coming from broken drain pipes directly outside. Through discussion with the Manager it was identifed that 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. Work has been scheduled on the home improvement plan and a copy was provided for inspectors. One of the residents who had recently moved into the home was pleased with the faciltites available and felt that this was more suitable in meeting her needs. Another resident spoken with had moved to a double room so that her partner was able to stay over night on occasions. Both rooms were comfortable and had been personalised with their own belongings. It was previously identified that the window in the main kitchen required a fly screens. Arrangements had been made to address this, however due to the window fitting this could not be done, alternative arrangements are to be made. In relation to the domestic tasks, designated staff are identified each day to undertake the cleaning. Those residents wishing too also offer help. As resident have their own kitchen they are able to prepare drinks and snacks. A rota has been developed so that two residents each day take responsibility for cleaning this area. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff are available to support people living at the home. More formal arrangements are to be developed around systems to support and develop the staff team. EVIDENCE: Information regarding the recruitment of new staff was looked at. Information seen included an application form, references and a POVA 1st check. The Manager must ensure that a recent photograph is held on file, that employment histories are explored where information is vague and documentation is clearly dated so that information can be clearly audited in relation to start dates and when checks were carried out. The Provider has recently changed companies with regards to signatories for the Criminal Record Checks and that it is hoped when further recruitment takes place that checks will be returned more quickly. There are currently 11 permanent and 1 short term residents living at the home. Staffing within the home comprises of double cover between the hours of 8am and 10pm. Specific members of the team are identified to carry out Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 20 the domestic tasks or cooking. In addition to this there is the Manager and deputy manager. Nights are covered by 1 waking staff between 10pm and 8am. Due to the recent recruitment, agency cover has been reduced to a minimum. The Manager is planning to cover these hours with a further permanent worker as residents prefer the regular members of the team as they already know the routines within the home. Information regarding training was also looked at. Courses have recently been undertaken in fire, safety, medication, adult protection, health and safety, food hygiene and 1st aid. Certificates are held on file. The Manager had previously completed a training skills audit however this was now out of date. The Manager is asked to update the information for the whole staff team ensuring they have received all the necessary training relevant to their roles and responsibilities. This is to ensure that residents are in safe hands and are competent to carry out their role, safely. Through discussion with the Manager it was evident that she had thought about other courses, which would equip staff with further skills and knowledge about how to support residents safely, these included managing aggression, de-escalation techniques and continuous professional development. Details were passed on again by the inspectors with regards to the Bury Training Partnership Group. At present the home is not a member however may wish to explore this as a wide variety of training opportunities in line with skills for care are offered to staff. Managers also have the opportunity to share information and ideas with managers from other services. Information was provided on the AQAA with regards to NVQ training. Of the 12 staff working at the home 3 have achieved NVQ and 5 are working towards the qualification. Supervisions have taken place however the manager acknowledges that they have not been as frequent as they should this has been due to the Manager being on maternity leave and changes within the staff team. The Manager explained that both she and the deputy manager would be taking a shared responsibility in this area. Discussion was held with regards to accessing appropriate management training, which would provide them with additional skills in carrying out their duties. The Manager also wants to explore the purpose of supervisions and areas of discussion with staff providing more of a learning and development opportunity. From observations made and through discussions with staff it appeared that they have a good understanding of the needs and behaviours of residents. Residents appear to have an open and friendly rapport with staff. Carr Bank House DS0000008422.V340770.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is motivated and clear about what improvements are need to develop the service further. The Registered Provider must monitor the home in accordance with the law to ensure that residents receive a good quality service and evidence that this has been done. EVIDENCE: The Manager is currently on maternity leave however has agreed to do some hours so that she can gradually introduce herself back into work. Management cover has been provided by the Registered Manager from the ‘sister’ home Laburnum House and the Deputy Manager. The inspectors rearrange the visit to the home as no one had been available during the first visit. Arrangements were made to meet with the Manager and Deputy Manager later in the week. The Provider also visited the home and spent time working with staff. Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 22 As identified at previous inspections the Manager had been completing the NVQ 4/Registered Managers Award however missed the deadline for submission. The Provider acknowledged that this was due to an error on their part and not that of the training providers. Due to this the Manager now needs to re-enrol so that submission can be made. Within her role, there is now a Deputy Manager and senior staff that each have delegated responsibilities, which in turn is overseen and monitored by the Manager. Although on leave the Manager could clearly evidence that she was aware and informed of events within the home and that a good working relationship had developed between her and the deputy with clear roles and responsibilities. Discussion was held with the Manager, and previously with the Provider, with regards to their understanding of the Inspection process under Inspecting for Better Lives including KLORA’s, the management review process and the expectation for services to evidence how they monitor and continuously develop their service. The Manager was also advised to complete the National Minimum Data Set for Skills for Care, which is supported by CSCI. Bury Training Partnership Group also provides quality training for all staff in line with Skills for Care as well as providing an opportunity for Managers to network and support each other. Information is held with regards to the Providers monthly visits as required under Regulation 26. Whilst this had been completed information was limited. The Provider was asked to expand on these, clearly evidencing that quality auditing and monitoring is being carried out. The Manager also explained that she too has previously carried out unannounced visits to the home to carry out checks and that out of hour shifts had also been undertaken so the routines and practice could be observed. This is a further area the Manager has identified which she feels will enable her to monitor and improve the service. In relation to quality assurance the Provider must demonstrate that a quality review of the service is undertaken ensuring feedback from residents and other stakeholders is taken into consideration and information is reflected in an annual quality report. A copy of the report should be provided to CSCI and other parties involved with the home. In relation to health and safety, action has been taken to address previous requirements. A number of records were examined with regards to checks carried out within the home. These included fire equipment and alarm, gas safety, electric certificate and small applicances. The manager has been asked to confirm with CSCI that action identified on the gas and electric certificates have been addressed. In house checks are also completed in relation to fire safety and water temperature checks. The Manager is requested to ensure that water temperature records specify the area checked and temperature reading. Carr Bank House DS0000008422.V340770.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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 3 2 3 X 2 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008422.V340770.R01.S.doc LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carr Bank House Score 3 3 3 X 2 X 1 X X 2 X 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. Standard YA2 Regulation 14 Requirement Detailed assessments need to completed for all new residents moving into the home ensuring needs can be met. Care plans need be reviewed on a regular basis ensuring information reflects the current and changing needs of residents and staff are clear about the support required. Risk assessment need to be reviewed and up dated to reflect changing needs. Where issues have been identified the appropriate action needs to be taken to ensure that residents are safe. Action needs to be taken with regards to the replacement of broken windows and the repairs to external areas of the home to reduce levels of damp. Information gathered with regards to the recruitment of new staff must include gaps in employment being explored and all documentation and checks being clearly dated so that information can be audited. DS0000008422.V340770.R01.S.doc Timescale for action 30/08/07 2. YA6 15 30/08/07 3. YA7 13 30/08/07 4. YA24 23 30/08/07 5. YA34 19 30/08/07 Carr Bank House Version 5.2 Page 25 6. YA35 18 7. YA36 18 8. YA37 9 8. YA39 24 9. YA39 26 10 YA42 13 A training skills audit of the whole staff team must be undertaken to ensure that they have received all the necessary training relevant to their roles and responsibilities ensuring staff are competent to carry out their role safely. A formal system of staff supervision needs to be developed to support them with their continued development. The registered manager must complete the registered managers award so that service users benefit from a qualified registered manager. In accordance with the law the Registered Provider should undertake a review of the quality of care provided by the home to ensure that feedback from service users, family, stakeholders etc is being considered by the registered provider as a means of quality assurance and improving service delivery. Evidence should be provided within an annual report. (Outstanding) Information recorded during visits made by the Registered Provider should be expanded upon to clearly evidence that the service is being monitored as part of a thorough quality reviewing process. That CSCI is informed that the identified work on the electric and gas certificates has been carried out to ensure the health and safety of service users. 30/09/07 30/09/07 30/09/07 30/10/07 30/09/07 30/08/07 Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 26 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 YA24 YA42 Good Practice Recommendations Alternative arrangements need to be made with regards to a fly screen being fitted to the kitchen window. Records in relation to water temperatures need to clearly detail the area checked and temperature reading. Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carr Bank House DS0000008422.V340770.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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