CARE HOMES FOR OLDER PEOPLE
Carrick Lodge Belyars Lane St Ives Cornwall TR26 2BZ Lead Inspector
Paul Freeman Unannounced Inspection 9th February 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.V258843.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V258843.R01.S.doc Version 5.0 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 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.V258843.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th June 2005 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 is Ms T Izatt. The providers state the aims and objectives of Carrick Lodge are to meet individual residents 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 individual need. Carrick Lodge is situated near the centre of St. Ives and is in an elevated setting with panoramic views of the bay. Accommodation comprises of 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.V258843.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two Inspectors undertook a planned unannounced inspection on 9 February 2006. A further inspection visit by the Inspectors was undertaken on 8 March 2006. This occurred in order that the management arrangements at the home could be considered and given the registered manager was not available on 9 February 2006. The purpose of the inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 15 June 2005 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 and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. Another inspection visit had occurred on 4 October 2005 in response to concerns that had been raised with the Commission about the admission arrangements and care and support provided to a resident. The concerns were not upheld. The requirements and recommendations set at the last inspection had been worked upon and the provider, staff and residents fully cooperated and were very helpful throughout the inspection period. What the service does well:
The providers to make sure the services and facilities available meet the person’s needs, preferences and choices assess each prospective resident. The prospective residents are invited to participate in the assessment and person’s relatives or representatives are also consulted. In additions the views of any speaclist workers involved with the prospective residents are taken into account. Residents that have recently moved to the home said they were positively welcomed by the staff and helped to settle in their new environment. The residents commented they found the staff to be “kind and respectful”. The information from the assessment process forms the basis for the care plan that details the care and support the individual requires. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 6 Each resident has a care plan that details their needs and provides staff with guidance and direction about the care and support required. There are some good examples of care planning and it is clear that the plans are regularly reviewed with the residents and their relatives or representatives. It is evident that residents are treated with dignity and respect and that every reasonable effort is made to provide residents with control over their lives. Staff is supportive of residents and make every reasonable effort to support each person to take decisions about their lives. Flexible visiting arrangements are in place so that residents are able to maintain links with their family and friends. There are also no barriers to residents accessing representatives or advocates where required. A varied and nutritional menu is also provided at the home and mealtimes are flexible. Residents have a choice of the meals they have and the menu reflects the residents’ preferences and choices. The providers also regularly consult with residents about the menu to make sure that all tastes are accounted for. Residents said they were satisfied with the meals and one described the food as “very nice”. Suitable arrangements are in place to positively deal with any complaints or concerns the residents may have. Residents and staff commented they felt comfortable about raising any issues of concern with the registered manager. The arrangements to protect residents from abuse are satisfactory and meet the guidelines laid down by the Department of Health. The registered manager and staff are clearly committed to taking positive steps to ensure that residents are properly protected. The care home comprises of 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 homely and comfortable environment. The home is decorated to a good 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 ensuite facilities. A laundry is situated on the ground floor and residents commented they were very satisfied with the service provided. The home was generally found to be clean and hygienic and residents said the housekeeping staff maintained a good standard. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 7 Residents said they were satisfied with the care and support they receive and commented they found the staff to be reliable, flexible and responsive to their wishes. The providers have established a progressive training programme for staff and apart from two staff all are qualified to a minimum of NVQ 2 standard. Many staff has also completed NVQ 3. In addition the providers offer a range of training opportunities in the core skills required to provide a good quality of care. It is also positive that each staff member has an individualised training programme that is regularly reviewed and updated. The providers have put in place a range of measures to make sure the services and facilities reflect the needs of residents and best practise. Residents, staff, visitors and professionals involved with the home are consulted about the quality of the provision. What has improved since the last inspection?
The assessments completed by the registered manager have continued to improve and clearly provide a good picture of the individuals needs, preferences and choices. This helps to make sure that a suitable care plan is in place that guides, directs and informs the staff. Where good assessments are completed the prospective resident is given confidence their needs will be met when they enter the home. The confidence levels are not so evident where assessments fall below the required standard. Equipment in the laundry has been replaced and the laundry room is being improved to assist the laundry staff in their work. Following the last inspection the providers have reviewed the mattresses and commodes provided at the home and replaced any items that did not meet the required standard. This has improved residents’ comfort and safety and made sure that individual needs are met. The staffing arrangements have been reviewed and additional staff is planned during waking hours to reflect the residents needs and improve safe working practices. Additional staff has been appointed to achieve this goal and this provides the manger with additional resources to also cover any staff absences. Some of the residents did comment that there were insufficient numbers of staff on duty at certain times. The new arrangements also appear to address the shortfalls identified by residents. The records at the home continue to improve but further development is required in certain areas to make sure the providers comply with the
Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 8 regulations. This will make sure that comprehensive information is available at the home. The arrangements to assess and positively manage risks experienced by residents also continue to improve. Further development is required to make sure that every reasonable step is taken to eliminate risks to residents and staff. There are some good examples of risk management but in other situations insufficient information to sufficiently guide and direct staff ios provided. What they could do better:
The registered manager has begun to involve experienced senior staff in the assessment of need arrangements for prospective residents. The introduction of senior staff has resulted in assessments that fall below the standard required. The registered manager is aware of the situation and has taken steps to make sure that detailed assessments are completed in all situations. Although the care planning arrangements have continued to improve there are still occasions when the required standard is not met. This mainly occurs when the assessment of the resident is not sufficient in scope or detail. The manager is aware of the situation and said they are in the process of addressing the shortfalls. Two of the communal bathrooms and a shower room are currently out of commission. One of the bathrooms has been in the process of refurbishment since January 2005, which has caused residents inconvenience and placed an additional burden on the staff group. The laundry floor is not watertight and this needs attention to make sure good health and safety arrangements are in place. 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. The requirement set at the last inspection to improve the recruitment, selection and vetting arrangements for staff has not been complied with. The records required by regulation and the appropriate vetting arrangements are not in place and could place residents at risk. A report must be completed for the quality assurance measures that were completed in 2005. The report will be available to interested parties and will detail the findings and any action plans that have been identified. The registered provider is also not comply with the regulations given no reports of the monthly visits required by the regulations have been received.
Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 9 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. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 10 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.V258843.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6. The admission process needs further attention in order that a clear picture is obtained of prospective residents’ needs and to make sure the home is able to meet the person’s assessed needs. The welcome provided to new residents is positive and helps them to settle in their new environment. EVIDENCE: The providers assess each prospective resident to make sure the facilities and services are able to meet the person’s needs. In addition the information obtained is used to develop a suitable care plan that directs the care and support required. The assessments take into account the views and opinions of any speaclist workers that are involved with the prospective resident. The assessments undertaken by the home continued to improve and the providers have begun to involve experienced senior staff at the home in completing assessments. Assessments completed by the registered manager
Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 12 are to a good standard but other assessments were not sufficiently detailed to provide a good picture of the prospective residents needs, choices and preferences. The registered manger said they were aware of this shortfall and were taking steps to make sure appropriate assessments were completed for all residents. Residents that had recently moved to the home said they had been invited to participate in the assessment process and were visited at their home so that their needs could be considered. The residents said the staff positively welcomed them when they were moved to the home and commented that staff were “kind and respectful”. Where quality assessments are completed it is evident that prospective residents are given confidence that their needs will be met when they enter the home. It is not evident this occurs where the assessments lack detail and principally provide a summary or general guidance about the care and support required. The care home does not offer a dedicated intermediate care or rehabilitation service. The providers stated they are committed to maximising resident’s independence and meeting individualised lifestyles. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10. Care plans continue to improve and there are examples of good care planning that clearly informs the staff of the care and support required. Residents are treated in a respectful and dignified manner that promotes their dignity, rights and privacy. EVIDENCE: The care planning arrangements continue to be improved and a high percentage of the plans examined detailed the person’s needs and provide suitable direction to the staff. It is clear that a good standard of care planning is in place providing robust and detailed assessments are completed. Where this does not occur the care planning arrangements are not satisfactory. This results in a lack of direction to staff about the care and support required or preferred. Residents social needs are identified and accommodated in plans that are separate from the care planning documents. The recreational plans are detailed and it is evident that the activity coordinator appointed at the home is
Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 14 a key resource in providing residents with a stimulating and varied lifestyle. The activity coordinators hours have recently been increased and this has provided more opportunities to work with residents on a one to one basis at the home and in the local community. The care plans also include a social history of the each resident which helps the staff to build a better picture of the individual and provides further guidance about meeting that persons needs and aspirations. Care plans are reviewed each month and suitable steps are taken when a change of need is identified. It is clear that staff treat resident with dignity and respect and make every effort to make sure that residents have control over their lives as far as possible. The Inspectors witness instances where staff offered appropriate advice and assistance to residents that help residents to make decisions in a positive manner. It was also evident that staff actively reassures residents when they experience any distress or are worried about something. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15. 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: The visiting arrangements at the home are flexible and residents said the arrangements “suited” them. Residents were confidant that visitors are well received and looked after and stated they are able to decide where they meet with their visitors. Residents were also very satisfied with the menu and food provided. Residents said that mealtimes are flexible and they are able to decide where they eat their meals. The residents described the food as “enough for me” and “very nice”. A varied and nutritional menu is in place that reflects the residents’ preferences and choices. The menu is also seasonally adjusted and residents are regularly consulted about the meals to make sure that their tastes and requirements are catered for.
Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: No complaints have been received by the home but one was received by the Commission. This complaint was not upheld. Residents and staff comments showed that people feel comfortable and confident about discussing any concerns with the Registered Manager. Suitable arrangements are also in place to positively deal with any complaints that occur. The adult protection procedures accurately reflect the guidance provided by the Department of Health. There are also suitable whistle blowing arrangements in place so that staff can report any concerns to a third party if they feel unable to raise the issues with the providers. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23 and 26. The environment is comfortable, suitably decorated and homely setting for residents and many of the bedrooms are persoanalised. The bathing facilities are not satisfactory and need urgent attention to make sure residents are not inconvenienced. A good laundry service is in operation but the laundry floor needs improvement to make sure good standards of hygiene are maintained. Good standards of hygiene and cleanliness are maintained around the home that promotes good health. EVIDENCE: Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 18 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 and registered manager have had made efforts to create a homely and comfortable environment. Residents were also generally satisfied with the facilities. 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 of this area to enable service users to safely access the garden. A small car park is provided at the front of the care home. The requirement to repair the inspection cover in the car park had been acted upon but there is still some remedial work required to complete the work and make sure it is not a hazard. 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 ensuite 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 that have to rely on a bathroom in another parts of the building. In addition some residents are 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. The Inspectors were told the registered provider was surprised about the comments regarding the sink given a similar sized sink is located in one of the toilets at the home. The Inspectors are making a proportional judgement as it would be not be viable to provide a full sizes sink in the toilet given space restrictions. This is not the case in the bathroom. The Inspectors were advised the bathroom was scheduled for completion by 31 March 2006. 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. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 19 Residents’ bedrooms and communal areas were found to be in a good state of repair and decoration and residents were generally satisfied with the facilities provided. Many of the bedrooms have also been personalised by the occupants. One bedroom can accommodate 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. Following the last inspection the manager has audited all the commodes and mattresses at the home and replacements have been provided where required. The home was generally found to be clean and hygienic and residents said the housekeeping staff maintained a good standard. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. The staffing arrangements continued to be reviewed and developed to make sure sufficient number of staff are on duty at all times to safeguard residents. The recruitment, selection and vetting arrangements for new staff are not satisfactory and could place residents at risk. Staff training is good and each staff member has an individualised training programme. This makes sure that staff is competent in the core skills required and have regular opportunities to develop their skills and abilities. EVIDENCE: The providers set staffing levels according to the number of residents and the residents’ needs. The minimum levels have recently been reviewed and it is planned to increase the staff on duty during waking hours. The providers consider this necessary to meet the needs of residents and to promote safe working practices. The duty rosters indicate there are regular occasions when staff fail to attend for duty. The registered manger stated that other substantive staff fill any gaps that occur on these occasions. The duty rosters do not evidence this has occurred but the registered manager stated that other records at the home would confirm that minimum levels had been maintained. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 21 Residents said they had confidence in the staff who they found to be attentive, responsive and flexible in their work. Some residents commented there had been occasions when they felt insufficient numbers of staff were on duty. The recruitment selection and vetting arrangements for new staff were considered and is was evident that a number of records required by regulation were not available for inspection. Theses included staff references and Criminal Records Bureau Checks. The current shortfall could potentially result in residents being placed at risk. The evidence indicates that new staff is provided with an appropriate induction programme that details their roles and responsibilities. This also makes sure that staff has the required skills and abilities to meet the needs of residents in a satisfactory manner. All the staff are also appraised by the providers on an annual basis and the appraisal identifies strengths and opportunities for personal development. The appraisals commence in April 2006 and when completed will also assist in the development of a training programme for the home. The home has continued to progressively provide the staff with training in the core skills required to provide a quality service and the NVQ qualification. It is positive that all of the staff apart from two members has obtained NVQ 2 and many also hold or are currently studying for NVQ 3. The manager has therefore continued to improve and develop the training opportunities for the staff and each staff member has an individualised programme. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 37 and 38. Positive measures are in place to monitor and review the quality of the services and facilities provided for residents. The management of risk is not satisfactory although this area has improved. Regular records are maintained but in certain instances more detail is required to make sure that a complete picture is provided. This will help the managers and staff to meet the residents’ needs, provide a safe environment and reduce the potential risks to residents and staff. EVIDENCE: The providers have established a range of measures to assess the quality of the services and facilities provided. The measures include consulting with residents, relatives and visitors to the home, staff and professionals that have regular contact with residents. In addition a number of audits are regularly undertaken about the care and support arrangements in place to make sure they reflect best practise.
Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 23 A quality assurance review was completed in 2005 but the report required by regulation for the residents and the Commission is outstanding. This needs to be completed so that residents their visitors and professionals have the opportunity to consider the contents and conclusions. The arrangements to safeguard residents financial interests are satisfactory and suitable records are maintained. Records at the home continue to improve and particular progress has been made with the records relating to individual residents. In other areas the records are not satisfactory and these have been addressed in other areas of this report. It is also noted that the requirement for the registered provider to send monthly reports to the Commission and registered manager as required by regulation has not been complied with. No reports have been received from the registered provider. It is positive that the registered manger providers the registered provider with a monthly management reports about the running of the home. The requirements regarding risk assessment and risk management were also considered. In certain instances there are good examples of positive risk management that effectively minimise the risks to residents and staff. In other instances the arrangements are not satisfactory and require improvement to make sure that every reasonable step is taken to protect residents. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 24 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 2 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X 2 X X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 2 2 Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 25 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 OP3 Regulation 14 Requirement Detailed assessments must be completed before a service user is admitted to the care home on a planned basis. The records maintained about service users must be developed to demonstrate that needs are met. All service users plans must be user friendly and completed in sufficient detail to guide, direct and inform the staff. All the bath and shower rooms at the care home must be functional and safe for use by service users. The bathroom situated near to room 7 that is currently being refurbished must be completed and ready for use. The laundry flooring must be impermeable to promote safe working practises. The staffing levels must not fall below the minimum required to meet service users needs and provide appropriate protection. The registered manger must inform the commission of any
DS0000008919.V258843.R01.S.doc Timescale for action 30/05/06 2. OP4 12,13 and 18 15 30/05/06 3. OP7 30/07/06 4. OP21 23 30/10/05 5. OP21 23 31/03/06 6. 7. OP26 OP27 13(4)(c) 16(2)(e) 18 30/04/06 30/07/06 8. OP27 18 and 37 30/07/06 Carrick Lodge Version 5.0 Page 26 9. OP29 19 10. OP33 24 11. OP37 26 12. 13. OP37 OP38 12 and 17 13 14. OP38 13 occasion where the staffing level falls below the required minimum. The arrangements for the recruitment and selection of staff must meet with the requirements detailed in the minimum standards and regulations. A written report must be completed and made available to the Commission and interested parties about the finding and conclusion of the quality assurance review undertaken in 2005. The registered person must visit each month to determine the quality of the services and facilities and send a report of their findings to the Commission. (Previous timescale of 30 January 2005 not met). The records required by regulation must be maintained to the required standard. The risk assessment and risk management arrangements must be improved to make sure that residents and staff safety is not jeopardised. The area around the inspection cover at the front of the building must be repaired. 30/04/06 30/05/06 30/04/06 30/07/06 30/05/06 30/04/06 Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP23 OP23 Good Practice Recommendations The care plan documentation should also include the recreational and social plans that are in place for service users. A standard sized sink should be fitted to the first floor bathroom currently in the process of refurbishment. The bedroom accommodating four service users should be converted to single occupancy rooms. Carrick Lodge DS0000008919.V258843.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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