Inspection on 14/10/08 for Carranmore

This inspection was carried out on 14th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Carranmore 14/09/06

Carranmore 19/12/05

Carranmore 14/07/05

Carranmore 19/01/05

Carranmore 05/08/04

Carranmore 23/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOME ADULTS 18-65 Carranmore 218 Warwick Road Carlisle Cumbria CA1 1LH Lead Inspector Liz Kelley Unannounced Inspection 14 October 2008 09:30 th Carranmore DS0000022570.V371718.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 Carranmore DS0000022570.V371718.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. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carranmore Address 218 Warwick Road Carlisle Cumbria CA1 1LH 01228 514180 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) carrranmore@croftland.plus.com The Croftlands Trust Mr Peter Cork Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (6) Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 6 service users to include: up to 6 service users in the category of MD (Mental disorder excluding learning disability) under the age of 65 years of age. up to 6 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age) Date of last inspection 14th September 2006 Brief Description of the Service: Carranmore is run by The Croftlands Trust, a non-profit making organisation, which runs a number of residential and community based services in the county for people with mental health problems. Carranmore accommodates up to 6 people who have, or who have had, difficulties in maintaining aspects of their mental health. The property is located on a busy road close to the centre of Carlisle, with good bus links and close to a wealth of local shops and facilities. The home is a large terraced, three-storey older property, which has been modernised and converted for its present use. On the ground floor there are two lounges, kitchen-dining room, office, utility room and toilet. One lounge is designated as the smoking area. On the first and second floors there are 6 bedrooms, and two bathrooms. At the rear is a small parking area and patio garden. All service users have individual bedrooms, each with a wash hand-basin. All referrals are made, and funded via the Integrated Health and Social Services Team. The current scale for charging is £373.69. A Handbook is available for prospective residents, which includes a summary of the latest Commission for Social Care Inspection report. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day. We (Commission for Social Care Inspection, CSCI) spent time with people living in the home and talking to them about their experiences. We also met with the manager and the staff on duty and looked at records relating to the running of the home and how people like to be supported to live their lives. We also sent out surveys as part of this inspection to get feedback from people living in the home, their relatives and representatives and other professionals involved with the home. Before the visit the manager completed an Annual Quality Assurance Assessment, which provided information about all aspects of the running of the home. On the day of inspection four people were at home. They were seen making their own choices on how to spend their time. For example, one person was out shopping, a couple of people watched TV and made cups of tea, one was tidying the kitchen, and another said they had decided to have a lazy day at home. What the service does well: People living at the home experience a good quality of life through the support of an experienced, and stable staff team. People stated they receive support in a warm and caring way from the staff team. People told us: “I have been helped a lot, emotionally, with my illness but also with things like budgeting. It’s a strong base for me” “In my years of living at the home I have always found the staff here to be courteous, friendly, helpful and supportive”. People report that staff help them to make both everyday decisions and to have control over their life. The overall picture gained by us was that people living at the home are being supported in a way that suits them and helps them manage and maintain their mental well-being. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has well developed procedures for introducing new people. This leads to successful placements where people are assisted to make informed choices and given support to settle. EVIDENCE: The Annual Quality Assessment, AQAA, sent in by the manager sets out how a new person is introduced to the home: “When a new service user is referred to home we check all information to make sure it is an appropriate referral for both our project and the client being referred, so that we can meet that persons needs and expectations. If someone is accepted we encourage gradual visits to the home and then longer stays if this is appropriate to the service user. We would be aware of various assessment needs of a service user and develop relevant care plans and risk assessments, to go with additional information which we have received from a care co-ordinator who did the referral.” People said they are given the opportunity to spend time in the home before making a choice. An individual member of staff is allocated to give them Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 9 information and to help them understand how the home is organised and run and the facilities and services available. One service user said “I visited this home before I moved in several times for meals and to be shown round the house before I actually moved in- so I got a pretty good idea of what life would be like here.” Another said “I was asked back for coffee by one of the other residents and one of the staff helped me choose my new bedroom carpet for the room I was to occupy”. Everyone living in the home returned a survey and all stated that they had enough information to help them make the decision to live there. The manager stated that they are looking at ways to redesign the brochure handed out to people to make it more user-friendly and to update certain sections such as staff profiles. The manager also needs to ensure that this document informs people of who the home is suited to and more importantly who it is not suitable for, for example people with mobility issues. Admissions are not made to the home until a full needs assessment has been undertaken, and these were seen in peoples files and included social work assessments and risk assessments. Admissions to the home, therefore only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The manager considers the application together with the staff team, where all information is shared and views are listened to and fully debated, before agreement is given for the admission. This leads to successful placements where people are assisted to make the right choice for them and given support to settle. Carranmore DS0000022570.V371718.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 good. This judgement has been made using available evidence including a visit to this service. Staff are committed to supporting individuals to lead purposeful and fulfilling lives as independently as possible. EVIDENCE: The service involves individuals in the planning of care which affects their lifestyle and quality of life. Staff understand the importance of people being supported to take control of their own lives. To help this a key worker system is in operation and each person meets at least once monthly with their key worker to discuss their progress and how they feel. The staff team keep comprehensive records and key issues are discussed at this monthly meeting. If changes are required the individual will be supported to set new targets and identify new needs they require support with. In this way individuals are encouraged to make their own decisions and choices. One person said “I have Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 11 been helped a lot, emotionally, with my illness but also with things like budgeting. It’s a strong base for me”. Since the last inspection the organisation has introduced new ways of working with people in an attempt to make some of the paperwork have more impact. The staff team have been using a tool called A “Mungo Star” which allows people to plot on a chart the progress they have made. Individual care plans are well organised and laid out in a format that clearly identified needs and how they were to be met. These were supported by additional information such as profiles and pen pictures to aid greater understanding and knowledge of the individual. Files also included details of a person’s mental health disorder and any restrictions imposed via the Mental Health Act or Power of Attorney Orders. The manager has had training in the Mental Capacity Act and is aware on its implications for people living at the home. For example in Risk assessments they include details of restrictions made on people, for example limiting cigarettes and alcohol, and they record where these have been agreed by the person. Appropriate input from relatives and review meetings with mental health professionals are also recorded when a person’s liberty is being restricted. Part of this process is to make people aware of any potential risks and to discuss these so the individuals can make an informed choice. The home has a daily residents meeting each morning to discuss and agree the plans for the day, for example whose turn it was to cook tea, and to agree chores and cleaning tasks for the day. This meeting is also used by people to voice any issues and concerns that they wish to discuss with staff and other residents. People said they found this very helpful in planning their day and resolving any problems. Carranmore DS0000022570.V371718.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): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to lead meaningful lives, having opportunities to participate in the community where they live, and to make choices on their lifestyle. EVIDENCE: People spoke of their varied lives at the home, people said they chose to have individual holidays or to go with other people in the home. Each person’s weekly routine is different and staff help to find things that interest each person. Some people go swimming, attend college, day services, and follow different hobbies and interests such as knitting. A number of people do not go to any day service and direct their own spare time. Some people said they liked to go into town a few times a week, and said the location of the home was good for this as they were on a regular bus route. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 13 Two residents spoke of a recent holiday where everyone had decided to go together, and how much they had enjoyed this. People living in the home have the opportunity to develop and maintain important personal and family relationships. Staff support this with sensitivity and respect of each family’s circumstances. People reported that staff have helped them to stay in touch with family and supported them to attended family events. Relatives who returned comment cards as part of this inspection all commented positively on the support their relative receives from the staff team. Where appropriate, people are involved in the domestic routines of the home, and were observed carrying out everyday chores such as preparing a meal and making cups of tea. The meal arrangements are very flexible and staff are able to respond to individual requests. Some people prefer to cater for themselves and this is encouraged. Menus and records sampled demonstrate that meals are of a good quality, and provide good nutritional value. The weekly menu is planned with residents and purchases for the menu carried out with residents who take turns help cook and shop. Individual shopping is also encouraged to develop independence and daily living skills. People living in the home also enjoyed a variety of take away meals and meals out. Specials diets and healthily meals are offered and conversation between with staff and residents demonstrated that they were aware of promoting healthy choices. Carranmore DS0000022570.V371718.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): 18,19,20, and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff encourage individuals to be independent and to take responsibility for their own health and personal care, but more attention could be given to the changing needs of residents. EVIDENCE: Records on peoples healthcare needs are well maintained and kept up-to-date, these are linked to care plans, and include monitoring sheets for specific issues. People are registered with a GP of their choice and have access to other members of the Primary Health Care team. Other checks such as opticians and dental checks are also recorded on Healthcare files. The majority of care delivered is in directing and enabling people to do as much as possible for themselves. Any personal care is delivered mostly in people’s own bedrooms, although recently this has not always been the case due to some people having to go to the top floor for treatment in their own bedroom and this has proved difficult. This demonstrates that the home is not suitable for people with mobility problems, being on three floors and having no Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 15 downstairs bathroom. As people at the home get older they may find it difficult to have their needs met. The home needs to pay more attention to the changing needs of residents, and to arrange for re-assessments to be carried out to assess the risk and to begin to help people to make plans for the future. People receiving services are happy with the way that staff deliver their care and respect their dignity and rights. Interactions were observed with staff and this was carried out in a sensitive and respectful manner to the people living in the home. One person said “The staff have helped me with my illness and I have far fewer episodes of being unwell.” Another person has been visited on a daily basis while in hospital to offer emotional support. The full staff team have completed medicines accredited training, and in addition also receive training from the pharmacy supplying medication on the handling of that system. When spoken to the staff team felt confident about handling medications and seeking reviews from GPs, and mental health professionals, if they felt this was needed. People are supported to manage their own medications and treatments, in these situations the staff provide a monitoring and advisory role. To further strengthen this area a recommendation was made to audit medications coming in and out of the home and for the manager to carry out random checks to ensure that systems are working efficiently. This is all good practice and ensures people’s medication is handled safely and managed in their best interest. Carranmore DS0000022570.V371718.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 adequate. This judgement has been made using available evidence including a visit to this service. People’s rights are generally respected but the staff team need to have a heightened awareness of these areas in order to respond appropriately in protecting people, and listening to their views. EVIDENCE: Carranmore has a complaints procedure, which is given to new residents when they move in to the home. The atmosphere in the home is open and friendly and residents stated that they can raise any complaints and usually appropriate action will be taken to resolve their concerns. There had been no formal complaint since the last inspection. People living in the home were observed freely expressing opinions on the home to staff. People said that they would feel able to speak to any of the staff and approach the manager with any issues they had, and often used the daily morning meeting to do this. One person said what they would do if they were unhappy with something: “Normally speak to a member of staff and usually the problem gets sorted. I have some idea of who I can speak to if this doesn’t help. However during my many years here there hasn’t been an occasion when I’ve had to speak to someone else other than staff when I’m not happy about something.” However another person reported that they had made a complaint but felt that the home had not taken it seriously and they had not felt listened to. There were no records of this complaint. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 17 The Home has induction training that covers basic adult protection issues and the various forms of adult abuse. However, the manager, who is the key person in managing allegations, had not received up-to-date training on local adult protection guidance, and said he would find this helpful. Staff had not had any refresher training in this important area. The organisation has recently handled an incident in another home and had not followed the local protocol. This demonstrates that we cannot be confident that any allegation would be handled in a way that protects people’s rights and well-being. The staff team need to have regular training in how to safe guard people and the local protocols and procedures. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely and comfortable environment that match their lifestyle needs. EVIDENCE: The Home is located on the outskirts of a well-served community, and is similar to the surrounding properties. People living in the home reported that they found the location very convenient and it suited their life style. People’s bedrooms are of a good size and individualised to each persons tastes and interests. However none have en-suite facilities and bathrooms are basic. As mentioned earlier the home is not suitable for people with mobility problems, being on three floors and having no downstairs bathroom. As people at the home get older they may find it difficult to have their needs met. This recently led to personal healthcare being carried out in the laundry. The home Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 19 needs to state these difficulties in its Statement of Purpose to prevent inappropriate placements. The AQAA states “We have a cleaning rota in place which all staff are aware of and sign a sheet when completed cleaning tasks. Contract Cleaners came in and did clean of bathrooms/kitchen and toilets. All downstairs carpets have been cleaned by outside contractor.” One person said “The home is usually fresh and clean as each resident has his/her own small cleaning job to do 5 mornings a week to keep us occupied and as it is regarded as our own home we each have to make a contribution towards the cleaning of it”. This all ensures that the home is generally kept clean, however when the arrangements to keep the home clean with the help of residents is not possible on some days other arrangements need to be put in place. For example on the day of this visit the area around the kettle was in need of a general clean, and the nearby wall also in needed of cleaning. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a competent, well-vetted staff team who offer good support to the people living at Carranmore. EVIDENCE: Carranmore has a core group of staff with a good mix of skills, experience, and gender, which reflects the profile of the people living at the home. There are staff in sufficient numbers to be flexible to meet people’s needs and to support individual activities, this is also helped by some people being able to go out unaided by staff. When interviewed staff are clear regarding their role and what is expected of them. The manager said they had adopted a much more thorough approach at selection and interview of the type of person they were looking for and the nature of the job. New employees are also expected to undergo induction training and sign an undertaking to attend core skills training essential for the role of supporting people with a mental health problem. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 21 This leads to good levels of confidence and satisfaction from people living in the home, relatives and professionals with the care that is delivered. Relative comment cards stated that staff know what they are meant to do, and that they are able to meet their needs. Another said “There is a feeling of “home” at Carranmore.” The Home follows the recruitment procedures of the organisation, Croftlands Trust. Staff recruitment files are held at the organisations head office, and a copy is also held in the home with access only by the manager to maintain confidentiality. All staff have CRB disclosure checks and a checklist ensures that all safeguards are put in place prior to an appointment. Upon appointment staff are issued with a handbook, which includes job descriptions and terms and conditions. Appointments are subject to a sixmonth probationary period. Croftlands has a code of conduct and all members of staff have a statement of terms and conditions. A member of staff who was interviewed confirmed these practices. The home has a framework for supervisions and appraisals, and these have been carried out to good standards; staff reported that these are helpful and they feel well supported by the manager and the organisation. Staff training continues and staff are keen to gain new knowledge and skills that will assist them in supporting residents. For example all staff have recently completed a Safe Handling of Medication training course to level 2 and all staff have a recognised care qualification- NVQ2/3. Staff also receive varied training to equip them with skills and knowledge to support residents. A rolling programme of training includes first aid, fire wardens, moving and handling, health and safety and courses relating to specific healthcare needs to support people. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of the people living there, they are safe and well cared for. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. Staff and residents spoken to confirmed that they felt that the atmosphere in the home was relaxed and supportive. The AQAA the manager completed was detailed and gave an honest evaluation of the strengths and areas for improvement within the home. The provider, The Croftland Trust, appoints an operations manager to carry out Quality Assurance checks. These are sent into the Commission for Social Care Inspection on a monthly basis. From these reports areas for improvement are Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 23 highlighted and the actions were checked at inspection. These were judged to work well in monitoring and improving the service for those living at the Home. The organisation issues all policies and procedures for the home in line with changes in legislation and good practice guidelines. However many of these had not been reviewed on an annual basis. The manager needs to ensure that this is carried out, and are relevant to the running of the home. The homes Quality Assurance system was also examined and this was deemed not to be working for this size and style of home, being far too complex with little benefit to people living in the home. The resulting action plans were meaningless and important responses where not addressed. The organisation needs to look at this and develop a system that is lead by the users of the service, is responsive and is not over burdensome. Routine maintenance and servicing records were up to date including the fire log and fire drills for staff and service users. There is a designated Fire Warden who is trained to oversee fire safety in the home. There is a maintenance log that records all repairs ensuring they are reported and resolved in a timely manner. The home provides a safe and comfortable living environment and there were no obvious hazards noted on this visit. Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x 2 2 x 3 x Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 25 NO 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The information supplied to people living in the home should be reviewed and updated to ensure it is accurate, including the statement of purpose and service user guide. Auditing medications coming in and out of the home should be undertaken and random checks carried out to ensure that medication systems are working efficiently. The manager needs to strengthen how it responds to informal complaints, and any issues that result from its own Quality Assurance Systems. The Quality Assurance System should be reviewed to determine if it is still effective to measuring quality in the home. The staff team need to have regular training in how to safe guard people and to better understand the local protocols and procedures in protecting people’s rights. 2 YA20 3 YA22 4 YA23 Carranmore DS0000022570.V371718.R01.S.doc Version 5.2 Page 26 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. 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