Inspection on 02/02/06 for Carrickfinn

This inspection was carried out on 2nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Carrickfinn 09/10/08

Carrickfinn 27/11/07

Carrickfinn 06/12/06

Carrickfinn 25/08/05

Carrickfinn 26/01/05

Carrickfinn 10/05/04

Carrickfinn 30/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Carrickfinn 29a St Werburghs Road Chorlton-cum-Hardy Manchester M21 OTL Lead Inspector Unannounced Inspection 2 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 Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 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. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Carrickfinn Address 29a St Werburghs Road Chorlton-cum-Hardy Manchester M21 OTL 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) 0161 860 5889 Sheila Devanney Mary Mills Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: Carrickfinn is a care home for older people providing personal care only for a maximum of 16 people. The home is situated in the Chorlton-cum-Hardy area of Manchester, within easy reach of Manchester City Centre and is well served by public transport to the neighbouring areas of Stretford, Stockport and Didsbury. The home is a two-storey building with a single storey extension to the rear of the property. The home is situated in its own grounds that have an established and accessible enclosed garden for the use of the residents. There are eight single and four double bedrooms situated, in the main, on the ground floor. The home does not have a passenger lift. First floor accommodation is restricted to those residents who can access stairs safely. The dining room and lounge are open plan. There is no separate no-smoking lounge area. The kitchen is situated next to the dining room. There are bathrooms and toilets situated on the ground and first floor. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 2 February 2006 over a four hour period. The inspection involved spending time talking with the manager and deputy manager of the home who was on duty at that time. Some time was spent looking at files, records and the home’s policies and procedures. A tour of the inside of the home was also carried out. At the last inspection carried out in August 2005 a number of improvements were identified that needed to take place. It is commendable that a high number of these were found to have been completed at the time of this inspection. Not all the standards were checked at this inspection and it is strongly advised that this report should be read together with the last inspection report to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? It is commendable that nearly all the improvements identified at the last inspection had been carried out or were in the process of being carried out. The home had made a significant investment in purchasing a new care plan package and computer system to support that package. The management team had worked hard to update all care plans, risk assessments and general resident information onto that new system. Information about the individual resident on each care plan was now written in such a way that it would be very clear to any member of care staff supporting that person how the support should be offered/given. Record keeping on each resident had improved since the last inspection. Each person now had an individual file in which staff wrote relevant information about the person and their daily lifestyle. Information written by the night staff was particularly good and gave a clear indication on what type of night the individual resident had spent. The general environment of the home had been improved since the last inspection. New carpets had been purchased for those areas identified at the Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 6 last inspection, as had new commodes. A number of rooms had been redecorated and looked much brighter. Formal supervision of staff had taken place much more frequently than previously and each member of the staff team had individual training and development plans/records on file. The management team had been much more proactive in arranging suitable packages of training for the staff in the home. 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. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 7 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 Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 8 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): 1,2, 3 and 6 Although information about the home was available to give to prospective residents this needed reviewing and updating. EVIDENCE: The home had a Statement of Purpose and a Service User Guide in place. However, this was dated 2003 and needed reviewing and updating to reflect the current service offered by the home. Discussion with the management team stated that no new residents had been admitted since the inspection carried out in August 2005. Since that inspection a new assessment document had been developed and included a risk analysis. The manager stated that all such information, once collated, would now be transferred to the computerised system and would be included in the new care planning format. The manager confirmed that Carrickfinn did not offer the facility of intermediate care. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 9 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): On going health care needs of residents have been identified and are being met. The non-adherence to medication policies and procedures could place residents at risk. EVIDENCE: Since the inspection carried out in August 2005 significant changes and progress had been made to the care planning process used by the home. The home had purchased a ‘professionally developed’ care plan package. This package is in the form of a computerised system and appeared comprehensive in format and details. The management team of the home had spent considerable time in transferring information onto the new system for each resident living in the home. To ensure that residents and staff have up to date information to be used on a daily and on going basis ‘hard copies’ of these documents were kept on the residents’ file. Evidence seen on those residents files examined indicated that reviews were being carried out on a monthly basis of both care plans and risk assessments. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 10 The manager stated that residents had been invited to be involved in developing the newly formatted care plans but most had declined the invitation. Wherever possible, care plans must be signed by the resident or their representative to show their involvement in the process. If declined, this should also be recorded in the residents’ notes. Observation of interaction between staff and residents during the course of the inspection indicated that staff were respectful in the way they supported the residents and also ensured that their privacy was respected by way of knocking on doors before entering and allowing people time in their own rooms should they wish it. Medication was administered via a Monitored Dosage System and all staff with the responsibility for administering medication had received appropriate training. However, after lunch, it was seen that one carer was sat in the dining room completing Medication Administration Records (MAR) retrospectively. When asked by the inspector what she was doing the carer stated that she was ‘signing for medication she had given at dinner time’. The carer was informed that this could place residents at risk and must not happen. Evidence was seen that written, clear instructions had been given by the deputy manager that all medication must be signed for “at the time of administration”. This was not being followed. Staff with the responsibility of medication administration must receive updated training to ensure that they are very clear about how to administer medication in accordance with required policies and procedures. There was no way of auditing the amount of “as and when required” medication as balances were not recorded. Medication such as this must be regularly audited and balances checked. Abbreviations used on the MAR were not clear and varied from those recommended to be used on the MAR. This made auditing some medication administration difficult and could also place residents at risk. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 11 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): 12,13,14 and 15 Residents have choice and support to meet their expectations and preferences regarding their daily lifestyle although social activities required further development. EVIDENCE: Since the last inspection conducted in August 2005 some improvements had been made to the way social activities had been arranged for the residents living in the home. An activities organiser had been employed by the home but had recently left and, at the time of the inspection, the home was trying to recruit a suitable person for this role. On the day of the inspection a number of staff and students from the local college were supporting residents in the home to participate in various activities. This included: card games, gentle exercise and jigsaws. Those residents involved seemed to be enjoying the interaction. No restrictions are placed on visitors coming to the home and the visitor’s book indicated that a number of residents had frequent visitors. A number of rooms viewed during the inspection indicated that choice had been given regarding personal possessions brought into the home. Rooms were found to be homely and reflected the character of the individual resident. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 12 Although a mealtime was not observed during this inspection the manager confirmed that alternative choices were always available to residents on a daily basis. The menus used are four weekly and are seasonally planned to allow for produce availability. The cook had responsibility for monitoring and recording things such as refrigerator and freezer temperatures. However, although a food probe was available it was not being used and therefore, residents could be placed at risk. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 13 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 The home has relevant policies, procedures and systems in place to enable concerns to be raised and protect residents from neglect and/or abuse. EVIDENCE: The home has a detailed complaints procedure and, since the last inspection, the method used to record any complaints made had been improved. The manager confirmed that no complaints had been received since the last inspection. The Commission had received no complaints. The home has a detailed policy and procedure relating to the protection of vulnerable adults, including the Local Authority’s multi-agency procedure ‘No Secrets’. Discussion with both the registered and deputy manager’s indicated that they were both clear on the procedure to adopt should any allegation of abuse be made. All staff in the home would benefit from further training in abuse awareness. The deputy manager confirmed that they were waiting a date to be provided from a tutor at North Trafford College to deliver this training. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 14 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): 19,24,25 and 26 The general environment of the home was clean, tidy and reasonably comfortable with systems now in place to protect the safety of the residents. However, action still needed to be taken on some external areas of the home, which could present hazards. EVIDENCE: Since the inspection carried out in August 2005 the management of the home had made a concerted effort to meet the requirements made at that inspection regarding the environment. New carpeting/floor covering has been laid in various parts of the premises and a number of rooms have been redecorated/painted. An audit of all bedrooms had been carried out and new commodes and other furnishings supplied where it was identified as required. The handy person had carried out an audit of the external woodwork of the home and plans to carry out repairs/replacement when the weather improves Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 15 to allow this to be done. It is acknowledged that the timescales given for this at the last inspection had not expired and has been reiterated in this report. Since the last inspection the hot water system had been checked by a suitably qualified person to ensure hot water emission is close to 44°C throughout the home. Water temperatures throughout the home must be checked regularly, with records kept, to ensure that the temperature is appropriately maintained and to minimise risks to residents. The home was found to be clean, tidy and free from any unpleasant odours. A previous requirement to provide a smoke free sitting room had still not been addressed and this requirement has been reiterated in this report. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 16 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): 27,28,29 and 30 The recruitment and training policies and procedures now in place provide sufficient competent and well-trained staff whose performance is now regularly monitored. EVIDENCE: No new staff had been recruited since the last inspection carried out in August 2005. As required at that inspection, Criminal Record Bureau (CRB) checks had been requested for all staff working in the home but had not been received at the time of this inspection. The requirement has therefore been reiterated in this report. Staffing rotas indicated that enough staff was on duty at any one time to meet the needs of those residents living in the home and the manager confirmed this. Two staff had successfully completed National Vocational Qualification (NVQ) training level 2 and a further 7 members of staff were working towards this qualification. All staff had individual records of training kept on their file and there was evidence that various training courses had been completed or were arranged for staff to undertake. These courses included: First Aid, Basic Food Hygiene, Moving and Handling and Risk Assessment training. A tutor from North Trafford College was delivering most training. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 17 Staff files still did not contain information/documentation as required in Schedule 2 of the Care Homes Regulations 2001. This was a requirement at the last inspection and has been reiterated in this report. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 18 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): 31,33,36,37 and 38 The home is run in the best interest of residents. EVIDENCE: The registered manager had the necessary experience to manage the home and as she had been in post for a number of years knew the residents very well. Since the last inspection carried out in August 2005 the manager has not received any training relevant to her role as registered manager. However, both the registered and deputy manager were, at the time of this inspection, waiting a date to restart their Registered Managers Award training. In order to try and further develop the service offered by the home, the management team gave residents, relatives and visitors to the home an opportunity to complete a questionnaire that asked relevant questions about the service(s) offered by Carrickfinn. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 19 The manager said this had been a ‘useful process’, especially with visitors. A number of visitors who had filled in the questionnaire had indicated that they were unsure of the complaints procedure and manager’s had made a good effort to individually discuss this procedure with those visitors. The manager said that she intended to send out similar questionnaires every 6 months. Evidence was available to show that staff were receiving formal 1-1 supervision on a regular basis. Annual appraisals were also being carried out. The management team were carrying out a full review of the homes records, policies and procedures at the time of the inspection. These will be fully examined at the next inspection. Although evidence was available to show that routine servicing of equipment used in the home had been carried out there was no Fixed Electrical Certificate available for inspection. The manager said that she would ensure a copy was sent to the Commission for Social Care Inspection to evidence that the wiring in the home was safe and did not place residents or staff at any risk. Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 20 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 2 2 Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 21 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 OP1 Regulation 4&5 Requirement The Service User Guide and Statement of Purpose must be reviewed and updated to reflect the current service provided by Carrickfinn. A copy of both documents, once completed, must be provided to the Commission for Social Care Inspection. (1) The manager must ensure that arrangements are made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (2) All staff with the responsibility for the administration of medication must receive updated and appropriate medication training. Timescale for action 31/03/06 2 OP9 13 10/03/06 Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 22 3 OP12 16 4 OP15 13 & 16 5 OP18 12 6 OP19 23 7 OP20 23 8 OP25 13 9 OP29 19 The manager must ensure that an appropriate programme of social activities is planned and arranged for residents to participate in should they wish to do so. The manager must ensure that the cook uses the food probe when preparing meals in the home. All temperatures must be recorded. The manager must ensure that staff are familiar with the Vulnerable Adults Policy, (including whistle-blowing) and that a rolling programme of training is commenced. (1) The barge boards identified to the deputy manager must be replaced (Previous timescale 25/11/05 not met). (2) A full audit of all external woodwork must be undertaken and repairs or replacement carried out where required. The home must provide a smoke free sitting room. The provider must submit a plan to CSCI to say how they intend to address this issue. The manager must ensure that hot water temperatures throughout the home are checked on a regular basis to ensure emission is no higher than 43°C and records kept. The manager must ensure that staff files contain information/documentation as required in Schedule 2 of the Care Home Regulations 2001 (Previous timescale 28/10/05 not met) DS0000021539.V279115.R01.S.doc 31/03/06 10/03/06 31/03/06 31/03/06 31/03/06 10/03/06 31/03/06 Carrickfinn Version 5.1 Page 23 10 OP33 24 11 OP37 17 12 OP38 13 The registered provider must 31/03/06 supply the Commission for Social Care Inspection with a copy of Regulation 26 report on visits that are carried out on a monthly basis. Records required by regulation 31/03/06 for the protection of residents and for the effective and efficient running of the business must be maintained and kept up to date and accurate (Previous timescale 25/11/05) A copy of the Fixed Electrical 10/03/06 Certificate (5 yearly) must be supplied to the Commission for Social Care Inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carrickfinn DS0000021539.V279115.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!