CARE HOMES FOR OLDER PEOPLE
Carrick Lodge Belyars Lane St Ives Cornwall TR26 2BZ Lead Inspector
Paul Freeman Unannounced Inspection 19th October 2006 10:00 X10015.doc Version 1.40 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 Carrick Lodge DS0000008919.V315918.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 Older People. 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. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Carrick Lodge Address Belyars Lane St Ives Cornwall TR26 2BZ 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) 01736 794353 01736 798621 Mr Ronald James Cottam Mrs Trudy Anne Izatt Care Home 38 Category(ies) of Dementia (18), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (18), Old age, not falling within any other category (20) Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Carrick Lodge is a residential home that is registered to accommodate 38 older people 18 of who can experience dementia or a mental disorder. The registered provider is Mr R Cottam and the Registered Manager post is currently vacant. The providers state the aims and objectives of Carrick Lodge are to meet individual resident’s needs in a manner that is not intrusive, but is respectful and promotes dignity and rights. Therefore the prime role of staff is to help, assist and enable service users when required and according to their individual needs. Carrick Lodge is situated near the centre of St. Ives and is in an elevated setting with panoramic views of the bay. Accommodation comprises a large three-floor house to which a two-storey extension has been added. The bedrooms are located in three distinct areas on the ground, first and second floors. The ground floor accommodation also consists of two communal seating areas and a conservatory, the dining room, kitchen area, laundry and two offices. Two lifts and a stair lift are provided to assist access to the upper floors. A fenced garden is situated at the front of the home. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two Inspectors completed a planned unannounced key inspection 19 October 2006. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 9 February 2006 and to inspect other core standards. Therefore some of the key standards considered included assessment of resident’s needs, care planning, staffing arrangements and safe working practises. The registered provider, residents, staff and visitors were consulted about the services and facilities provided. The environment, records and documents were also considered. The current weekly fees are determined by the needs of each resident. What the service does well:
For each prospective resident the provider undertakes an assessment of need. The prospective resident, their relatives or representatives and relevant specialist workers are also invited to contribute to the assessment. Residents’ health needs are well met and medical services are promptly accessed when required. Prescribed medicines are also stored and administered safely to make sure that residents’ health is promoted. Observations of care showed that trusting and positive relationships occur between the staff and residents. Staff reported they found the care plans to be informative and to give good information about the care and support required. Visitors to the care home were generally satisfied about the care but certain visitors commented that improvements could be made given they did not feel that some staff paid sufficient attention to detail. This included how their relatives were dressed on occasions. Residents are provided with a varied and stimulating lifestyle and are actively supported to make their own decision as far as possible. A well-established programme of recreational activities is in place each weekday that reflects the residents’ choice and preference. Residents are provided with a varied menu that reflects their needs and preferences and promotes health. The kitchen and equipment is maintained to Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 6 the required standard and suitable arrangements are in place to promote health and safety. Appropriate arrangements are also in place to deal with any complaints or concerns raised with the registered provider about the operation of the care home. Suitable arrangements have also been established to safeguard residents from abuse and any concerns or allegations are reported to the statutory authorities. The care home comprises three distinct bedroom areas that are not interlinked and three communal areas on the ground floor. The residents are satisfied with the facilities and it is clear that efforts have been made to offer a comfortable setting. The home is decorated to a reasonable standard and many of the residents’ bedrooms have been personalised. A number of toilets and bathrooms are distributed throughout the home and some of the bedrooms also have en-suite facilities. A laundry is situated on the ground floor and residents commented they were very satisfied with the service provided. The staff is appropriately trained and positive and trusting relationship are in place between residents and staff. New staff complete an induction programme to make sure they are competent to meet the needs of residents. In certain circumstances the provider will assist residents to manage their personal allowances. Where this occurs the monies are held in secure facilities and suitable records are maintained. A range of measures is also in place to promote safe working practises and to safeguard residents and staff. What has improved since the last inspection? What they could do better:
The assessments of prospective residents need to provide sufficient detail in order that the provider has a full picture of the individuals needs, preferences and choices. Additional staff should be employed when the dedicated activities coordinator is unable to attend the care home. This will make sure that residents are provided with a varied lifestyle.
Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 7 A record of all complaints and the action taken by the registered person must be in place. Two of the communal bathrooms and a shower room continue to be out of commission. One bathroom has been in the process of refurbishment since January 2005. This results in inconveniencing residents and places an additional burden on the staff group. Urgent improvement is required so that residents can easily access facilities. Following the inspection the registered provider has written and confirmed one of the communal bathrooms will be made available to residents. The laundry floor is not watertight and this needs attention to make sure good health and safety arrangements are in place. No additional work appears to have been undertaken on the laundry refurbishment. This also requires urgent attention to make sure that residents’ health and welfare are not potentially compromised. One large bedroom accommodates four residents and it is recommended this be changed to a single occupancy arrangement at the earliest opportunity. This will improve the quality of the service and the occupants’ rights to privacy. A number of residents and visitors commented that offensive odours were regularly evident. The provider must take urgent steps to make sure a good standard of hygiene and cleanliness is maintained at all times. There are occasions when the minimum staffing levels are not in place and this could place residents at risk. The recruitment, selection and vetting arrangements require improvement to make sure that residents are safeguarded. The records about the induction completed by new staff require improvement. This will assist the registered providers to be satisfied that staff have the appropriate skills, knowledge and abilities and to safeguard residents. The registered manager post is vacant and recruitment is currently underway. The provider has not formally informed the Commission of the vacancy or detailed the interim arrangements in place. This is required in order to make sure that the arrangements are satisfactory. Fire detection and prevention staff training does not occur at the frequency recommended by the Fire Brigade. This requires improvement so that staff has a clear understanding of their roles and responsibilities and residents are safeguarded. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 8 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. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment arrangements require improvement to make sure the provider has a clear picture of residents needs, preferences and choices. EVIDENCE: Each prospective resident is assessed in order that the provider can be satisfied the services and facilities are suitable to meet their needs. The residents are invited to participate in the assessment and their relatives or representatives are also consulted. In addition the provider also endeavours to consult with any specialist workers that are involved.
Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 11 A sample of the assessments of residents that had recently moved to the care home was considered. In certain instances some of the assessments were found to be incomplete. On other occasions there was only limited evidence that specialist workers opinions had been obtained. The shortfalls of the assessments appear to correlate with the departure of the registered manager and the introduction of different senior staff undertaking this role. This is an area that requires improvement to make sure that staff have a clear picture of the care and support required and the residents’ preferences and choices. The provider does not offer a dedicated rehabilitation or intermediate care service. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were7, 8, 9 and 10. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to plan the care each resident requires but the provider must make sure the current standards are not compromised given the interim management arrangements. Good arrangements are in place to make sure residents’ health needs are met. Prescribed medicines are stored and administered reliably in order that residents’ health is promoted. EVIDENCE: Each resident has a care plan that details their needs and provides staff with direction, information and guidance about the care and support they require.
Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 13 The care plans are reviewed at regular intervals to make sure the most appropriate services and facilities are in place. The care plans are reviewed but the records of the review are limited. More detailed information about each review would benefit the staff. In one instance no care plan had been established. The provider needs to take steps to make sure that each resident has a good quality care plan that meets each individual’s health and welfare needs. The provider also needs to take steps to make sure the current standard of care planning is not compromised. Resident’s health needs are well met and good arrangements are in place to access health services promptly. Health professionals regularly visit residents and this was evident during the inspection when a District Nurse and General Practitioner visited different residents. The District Nurse said they were satisfied with the care and support provided and stated that good communication occurred at all times. Residents are able to administer their own medicines when it is safe to do so. Where staff assists residents the medication is held in secure facilities and suitable records are maintained. Suitable arrangements have also been established to safely dispose of medicines that are no longer required. The providers does need to make more suitable arrangements to make sure that controlled drugs are maintained in a double locked facility and the dedicated fridge for medicines is secure. This will ensure that residents are safeguarded. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a varied lifestyle that includes a range of recreational opportunities. The programme of activities is interrupted when the dedicated staff is absent and this has a negative impact on the residents lifestyle. Flexible visiting arrangements are in place so that residents can maintain contact with relatives and friends. A nutritionally balanced diet is provided that reflects the residents’ preferences and choices and promotes good health. EVIDENCE: It is clear that staff makes efforts to assist residents to maintain their independence and have control over their daily lives as far as possible. There are no barriers to residents receiving visitors and the arrangements are flexible. Many of the visitors commented upon the warm and friendly greeting they received from the staff. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 15 There is a range of recreational opportunities provided each weekday and a varied programme has been established. An activities coordinator has been appointed who has taken steps to improve the recreational opportunities and to make sure they reflect the residents’ interests. On the day of the inspection the post holder was away from work and the programme had therefore been interrupted. Additional staff had also not been put in place to make sure that residents stimulation and interests were not interrupted. This is an area that would benefit from improvement so that residents are provided with a varied and stimulating life style. A varied menu is offered that reflects the residents’ needs and preference. Residents and visitors said they were satisfied with meals and the choice provided. However, some residents reported that some of their favourite menu items were no longer available. This matter needs to be explored by the registered person. The kitchen and kitchen equipment is maintained to the required standard and appropriate measures are in place to promote safe working practises. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A suitable policy and procedure have been established for complaints and the registered provider has dealt with two issues following the last inspection. The records of the complaints were not available for inspection. The arrangements allow residents relatives or representatives to raise any concerns. Satisfactory arrangements are also in place to protect residents from abuse and any concerns are notified to the statutory authorities for investigation. This proves residents with a reliable safeguard. EVIDENCE: The provider has received two complaints following the last inspection. The registered provider said the matters had been dealt with in line with the established policy and procedure. The Commission has received no formal complaints. The Adult Social Care Directorate have also considered concerns that have been raised by relatives but the Commission is not aware that any significant issues were identified following their enquiries.
Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 17 The records regarding the complaints were not available for inspection and the registered provider said they were not aware of a log that was in place to detail any complaints or concerns, the action taken and the outcome. Satisfactory arrangements are in place to protect residents from abuse and any allegations or concerns are reported to the statutory authorities for investigation. A suitable whistle blowing policy is also in place to enable any staff to report any concerns to a third party. This provides an additional safeguard for residents. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 19, 2 and 28. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is comfortable and many of the bedrooms are personalised. The bathing facilities are not satisfactory and need urgent attention to make sure residents are not inconvenienced. A laundry service is in operation but the current refurbishments need to be completed in order that good standards of hygiene are maintained. There are regular occasions when offensive odours are evident and hygiene and cleanliness need to be improved so that good health practises are maintained. EVIDENCE: Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 19 The care home comprises three distinct bedroom areas that are not interlinked and three communal areas on the ground floor. The tour of the home indicated the registered person has made efforts to create a comfortable environment. Residents were also generally satisfied with the facilities. In some areas the standard of decor was good but other places were beginning to show signs of wear and tear and requiring redecoration. Two lifts and a stair lift are provided at the home and all are regularly serviced and maintained. Attractive grounds are located at the front and side of the building. The garden at the front of the care home has a steep elevation. The registered person has fenced off an area to enable service users to safely access the garden. A small car park is provided at the front of the care home. A number of toilets are distributed throughout the home and are within a reasonable distance from communal areas and residents bedrooms. A number of bedrooms are also provided with en-suite facilities. Two of the bathrooms on the third and second floor of the main building are out of commission. The shower facility on the ground floor is also not in service as it is considered unsafe. One of the bathrooms is used as a storeroom and the second has been in the process of refurbishment, which commenced in January 2005. This places an additional burden on staff and residents who have to rely on a bathroom in another parts of the building. In addition some residents are further inconvenienced given the facilities are not readily available. The sink in the bathroom in the process of refurbishment is not standard size and this could prohibit access for some residents. Following the inspection the registered provider has written to the Commission to advise they have given instructions for the third floor bathroom to be cleared. When this is completed the bathroom and toilet will be available to residents. The position regarding the bathrooms has not changed for sometime and urgently requires improvement. Then last inspection report stated “new equipment has been provided for the laundry and the facilities are currently been improved and updated. The laundry staff were positive about the plans which will assist their work given the layout will be improved. The floor in the laundry was also found not to be impermeable and requires urgent attention”. No further work appears to have been completed and this also requires urgent attention. Residents’ bedrooms and communal areas were found to be in a reasonable state of repair and many of the bedrooms have been personalised by the
Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 20 occupants. One bedroom is registered to accommodate up to four residents and it is recommended this be converted to single occupancy at the earliest opportunity. This will provide residents with the privacy they require. The home was found to be generally clean but a number of residents and visitors commented that offensive odours were evident on a regular basis. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff group have the appropriate skills; knowledge and abilities to meet the needs of residents and are appropriately trained. There continues to be occasions when the minimum of staff required is not on duty and this places residents at risk. The recruitment selection and vetting arrangements continue to require improvement to make sure that residents are safeguarded. New staff complete an induction programme but the records are incomplete. The provider is therefore unable to determine that staff has the required skills and knowledge to meet the needs of residents. EVIDENCE: There continue to be occasions when the minimum numbers of staff are not on duty and at theses times it is considered that residents are potentially placed at risk given their needs and the layout of the setting. In addition the care staff are also undertaking certain laundry duties that takes them away from the principal task of providing care and support to residents.
Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 22 The staff said they were clear about their roles and responsibilities and it is evident that positive and trusting relationships have been established. Residents and visitors were also positive about the care and support provided by the staff. The staff is generally appropriately trained and a number hold the NVQ 2 qualification. In addition training has been regularly provided in core skills to make sure that staff has the appropriate skills and up to date knowledge. Newly appointed staff undertakes an induction programme and initially work alongside experienced members of staff. However in certain instances no induction records were available for inspection. Recently appointed staff said the induction programme had been comprehensive and provided the information required in meeting the residents needs and preferences. The staff said they were well supported and information, guidance and advice were readily available. The recruitment selection and vetting arrangements require improvement given that new staff is commencing duties before a satisfactory POVA check was completed. This potentially places residents at risk. The requirement is therefore re-notified and urgent action is required. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 31, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered managers post is currently vacant and temporary arrangements are in place but the provider has not evidenced to the Commission the present arrangements meet the statutory requirements. A range of measures are in place to promote safe working practises and safeguard residents but the arrangements regarding fire training for staff do not meet the Fire Brigade guidance and require improvement so that residents are not placed at risk. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager left the employment of the registered provider some weeks ago and currently the provider is recruiting to fill the vacancy. In the interim the deputy manager and a senior member of staff are managing the day to day operation of the services and facilities under the supervision and guidance of the registered person. The provider has not formally written to the Commission to advise of the current position or to detail the interim management arrangements. In addition the Commission has received no information or documentation to evidence the current temporary mangers are fit to undertake the required duties and responsibilities. In certain instances the provider will assist residents to manage their personal allowances. Where assistance is provided suitable records are maintained and the monies are kept in secure facilities. Appropriate policies and procedures are in place to promote safe working practices and any situations that arise that could compromise the health and safety of residents are risk assessed. A suitable risk management plan is then put in place to minimise the risk. Suitable arrangements have also been established to regularly monitor and maintain the fire prevention measures. However staff training does not take place at the required frequency to make sure that all staff has a good understanding of the procedures and their roles and responsibilities. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 2 Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation Requirement Timescale for action 30/12/06 2. OP16 3. OP21 4. OP26 5. OP26 6. OP27 14(1)(a-c) Detailed assessments must be completed in order that the registered person can determine the care home is suitable to meet the service users needs in respect of health and welfare. 17(2) A record of all complaints about Sch 4 the operation of the care home, (11) and the action taken by the registered person in respect of any complaints must be provided and available for inspection. 23(2)(j) All the bath and shower rooms at the care home must be functional and safe for use by service users. (Previous timescale of 30 April 2006 not met). 13(3) The care home must be kept free 16(2)(j-k) of offensive odours and appropriate standards of hygiene must b maintained at all times. 13(4)(c) Suitable facilities must be 16(2)(j) provided to launder cloths in a manner that promotes service users health and wellbeing. 18(1)(a) The staffing levels must not fall below the minimum required to meet service users needs and
DS0000008919.V315918.R01.S.doc 30/12/06 30/04/07 30/12/06 30/01/07 30/01/07 Carrick Lodge Version 5.2 Page 27 7. OP29 8. 9. OP31 OP31 10. OP38 provide appropriate protection. (Previous timescale of 30 July 2006 not met). 19(5)(d) The arrangements for the (i) recruitment and selection of staff Sch 2 must meet with the requirements detailed in the minimum standards and regulations. (Previous timescale of 30 April 2006 not met). 8(1)(a) The registered provider must appoint a registered manager. 9(1)(1)(a) The registered provider must (2) write to the Commission to advise of the interim management arrangements and provide documentary evidence of the post holder’s fitness. . 23(4)(dThe registered person must e) make adequate arrangements for persons at the care home to receive at regular intervals suitable training in fire prevention and procedures. 30/01/07 30/01/07 30/11/06 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12 OP23 OP7 Good Practice Recommendations The programme of activities should not be interrupted when the dedicated staff are not able to undertake their planned duties. The bedroom accommodating four service users should be converted to single occupancy rooms. The care plan documentation should also include the recreational and social plans that are in place for service users. Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 28 Carrick Lodge DS0000008919.V315918.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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
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