Inspection on 25/08/05 for Carrickfinn

This inspection was carried out on 25th August 2005.

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

Other inspections for this house

Carrickfinn 09/10/08

Carrickfinn 27/11/07

Carrickfinn 06/12/06

Carrickfinn 02/02/06

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 0TL Lead Inspector John Oliver Unannounced 25 August 2005 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 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 F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Carrickfinn Address 29A St Werburghs Road Chorlton - cum - Hardy Manchester M21 0TL 0161 860 5889 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sheila Devanney Mary Mills Care home only (PC) 16 Category(ies) of Old age, not falling within any other category registration, with number (OP) (16) of places Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 January 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 F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 25th August 2005 over a five hour period. The inspection involved spending time talking with the deputy manager and staff of the home who were on duty at that time. Some time was also spent with one particular resident who wanted to say how he found living in the home. Some time was spent looking at files, records and the home’s policies and procedures. A tour of the inside of the home was carried out as well as having a walk around the outside of the building. At the last inspection, which took place in January 2005, a number of improvements were identified that needed to take place. A high number of these were found to be still in need of completing at the time of this inspection. Those improvements still not done have been included again in this report. Not all the standards were checked at this inspection and it is strongly advised that this report should be read in together with the last inspection report and any future inspection reports 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? Staff had received some work related training since the last inspection. Two new heating boilers had been installed since the last inspection. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 6 The management team of the home now had the support of a number of ‘professional’ organisations for the development of policies, procedures, and, health and safety matters. Staff training had been further developed and the deputy manager confirmed that all care staff had been enrolled to commence National Vocational Qualification (NVQ) Level 2 training. What they could do better: Care plans were not fully completed nor did they identify any changes that may have taken place to the care an individual resident may need. Checking the plans on a monthly basis would help to make sure that residents could remain as independent as possible with the right support being available when required. Daily information on each resident was recorded in a ‘log’ book. This does not maintain the confidentiality of each person living in the home. The deputy manager was able to identify a different way to do this in order to maintain confidentiality. Record keeping was generally poor. Both resident and staff files were not kept in an ‘orderly’ fashion and, information that should have been available on files was not. Records maintained on a day to day basis about the health and wellbeing of residents living in the home were ‘institutional’ and alternative systems of record keeping must be developed. Of some concern was the lack of Criminal Record Bureau (CRB) checks being carried out for staff employed in the home. Although the deputy manager said that these checks had been applied for there was no evidence on staff files. A Criminal Record Bureau check must be carried out for every member of staff working in the home. Staff must be employed correctly so that people living in the home are protected from people who should not be working there. Although the home was generally tidy and free from ‘clutter’, one bathroom was being used to store continence products, which prevented full access to move freely around the room. All areas that residents have access to must be kept clear of any hazards. A number of carpets throughout the home were looking ‘tired’ and, in some places, where there are a lot of people, carpets would benefit from being ‘deep cleaned’. Some furniture was also in need of being replaced. This would ‘add’ to the overall ‘presentation’ of the home. The decoration in a number of rooms was also beginning to look ‘tired’ and ‘untidy’, especially where wallpaper was torn or coming away from the walls. A rolling programme of decoration and maintenance would be a useful way of monitoring and maintaining this. Again, carrying out this work would ‘add’ to the overall ‘presentation’ of the home. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 7 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 F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 3 and 6 In most cases, prospective residents were being assessed prior to admission into the home. EVIDENCE: The file of one resident recently admitted to the home was examined. This contained the Care Management Assessment and the pre admission assessment carried out by the deputy manager of Carrickfinn. However, further details were required such as personal safety and any risks that may be apparent. Healthcare professionals from other agencies were seen to visit individuals in the home during the inspection. Case notes also gave some indication of the regular and consistent interaction from healthcare professionals. Such information helped to confirm that the needs of residents were being met at the time of this inspection. Carrickfinn did not offer the service of intermediate care and the deputy manager confirmed this. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7 and 8 Limited progress had been made since the last inspection on improving the arrangements to ensure that the on going health care needs of residents are identified and met. These shortfalls have a potential to place residents at risk. EVIDENCE: Individual plans of care were available in the home but little progress on meeting the requirements made at the last inspection has been done. The plans remain basic, were not up to date and had not been reviewed. Risk assessments had not been fully completed or were not in place. Significant events in the home had not been recorded; daily entries into the ‘daily log’ book gave little indication of the actual care given. This was particularly evident for one resident who, via some information in an accident record had sustained a fall. No record of this or any risk assessment or associated plan or preventative measures had been further identified. Discussion with one particular resident did indicate and suggest that some individual needs were being addressed even though there was a lack of clear plans and guidance. Much of the care being delivered by the staff in the home was dependent on staff memory and reliance on verbal communication. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 11 If this practice continues, residents are at risk of not having their health care needs met in the most appropriate way. This situation must be addressed. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 Social activities required further development. EVIDENCE: It is commendable that the home has recently employed a person with specific responsibility for arranging a programme of activities in Carrickfinn. However, at the time of the inspection, an audit of the people living in the home had not been carried out and, therefore, the likes and dislikes of individuals regarding social activities was not known. This would make planning a suitable programme of activities difficult. During the inspection residents were seen to be watching TV and reading magazines. There is a large, well kept and accessible rear garden that most residents enjoyed sitting in when the weather permitted. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 Complaints, although recorded, lacked relevant information. The home’s noncompliance with policy and procedure relating to protecting vulnerable adults from abuse places residents and staff at risk. EVIDENCE: The home has a detailed complaints procedure but the method of recording complaints lacked consistency. The record must clearly demonstrate the process used during the investigation of any complaint, the conclusion of the complaint, and must include the date and signature of the manager once the complaint is concluded. This would clarify that all the procedures identified within the complaints procedure had been appropriately carried out. Although 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’ a recent incident that should have been investigated using this procedure was carried out and concerns were raised with regard the process of investigation adopted by the manager. Non-compliance with such procedures can place residents and staff at risk. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,23,24 and 26 Overall the general environment of the home was clean, tidy and reasonably comfortable. However, not all systems in place ensured the comfort and safety of the residents living in the home. EVIDENCE: Evidence available indicated that some routine renewal and maintenance of the home had taken place since the last inspection. Not all rooms were seen during the inspection, however, those rooms seen, did indicate that some work relating to re-decoration, and carpets and furnishings needed carrying out. This would enhance the living environment of a number of residents. Carpeting on the corridors and in the lounge areas were badly marked and in a poor condition. The carpets must be ‘deep cleaned’ or replaced. Three bedrooms needed to be redecorated to provide a comfortable environment for the residents using them (these rooms were identified to the deputy manager during the inspection). Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 15 One bedroom had a strong odour of urine and this was permeating from the carpet. This carpet must be replaced to provide a safe and comfortable environment for the resident. All continence products stored in the ground floor bathroom must be moved to a suitable storage facility to ensure that residents have full access to communal facilities and are not at unnecessary risk when using those facilities. An appropriate door plate required fixing to the carpet edge leading into the downstairs bathroom to reduce the risk of tripping. Commodes in a number of bedrooms were found to be ‘rusty’. A full audit of all commodes must be undertaken and replaced where necessary. At present some of the commodes were not suitable to be used by frailer people. The light fitting in the main hallway had been removed. This must be replaced to ensure sufficient lighting is available to those at risk from slips, trips and falls. The rotary iron stored on the upstairs landing must be removed to a suitable place to ensure that residents have full access to communal facilities and are not at unnecessary risk when using those facilities. Although the deputy manager confirmed that mixer valves had been fitted to hot water outlets and two new combi-boilers had recently been installed, a number of hot water taps were running below the required minimum temperatures. An audit must be undertaken of all hot water emissions throughout the home that are accessible to residents. This must be carried out to ensure appropriate temperatures are maintained for the comfort and safety of residents living in the home. All bedroom doors had locks fitted. These locks could not be overridden using a ‘master’ key. All locks had separate keys to gain entry should the door be locked. This creates a potential risk to residents in an emergency situation. A suitable alternative lock, or, master keys must be obtained. The barge boards identified to the deputy manager at the rear of the property were rotting and ‘falling away’. A full audit of all external woodwork must be undertaken and repairs or replacement carried out where required to ensure the comfort and safety of residents living in the home. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29 and 30 The procedures for the recruitment of staff are not robust and do not offer the necessary protection to people living in the home. EVIDENCE: The staff file of a recently employed member of staff indicated that the home had not undertaken all the necessary recruitment checks to ensure the protection of residents. Criminal Record Bureau (CRB) checks had not been requested prior to employment commencing. The deputy manager stated that CRB checks had now been requested for all staff working in the home. One resident spoken to said that staff at the home were “excellent” and “management is lovely”. Observation of staff indicated that they responded to the needs of residents quickly. During the visit one call alarm was tested and staff were quick to respond. A number of ‘professional training packages’ (including videos) had been purchased by the home that includes Basic Food Hygiene, First Aid, Moving and Handling, Challenging Behaviour, Abuse and, Health & Safety. Evidence was available to show that staff had received training using these in-house ‘packages’ and certificates had been produced and put on staff files. However, this type of ‘in-house’ training does not demonstrate that individual members of the staff team have achieved suitable levels of competence. Mandatory training such as Moving and Handling, Basic Food Hygiene and, First Aid must be carried out by people trained to deliver such courses and with the skills to identify competency level of the individual receiving the training. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 17 The deputy manager stated that all care staff had been enrolled to commence NVQ Level 2 training. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36 and 37 Not all management practice ensures that residents receive consistent quality care. This results in some practices that do not promote and safeguard the heath, safety and welfare of the residents living in the home. EVIDENCE: Lack of consistency in management approach to running the home was creating poor communication. This has resulted in some poor administrative practices, which could place residents and staff at risk. Whilst residents and staff made positive comments about the management team, evidence of some administrative practice raised a number of concerns. Personal details relating to the daily health and welfare of residents were maintained in an A4 ‘log’ book. Information seen in this ‘log’ was very brief and did not reflect the care and support that should be given to the individual. Confidentiality could not be maintained should a resident request to see the Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 19 ‘daily’ record kept on them. An alternative system to record the day to day information on each resident living in the home must be developed. A number of Policies and Procedures had been developed by a ‘professional’ organisation to support the management and staff team carry out their duties. The registered manager had signed and dated these documents to confirm her agreement with them. However, evidence was available to indicate that the registered manager did not follow relevant policies and procedures when carrying out her duties. This does not help to promote and safeguard the health, safety and welfare of residents living in the home. There was no evidence that staff receive formal supervision. Staff files did not contain individual development plans. This did not offer staff opportunity to discuss their personal/development needs. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 1 3 x 2 1 1 1 STAFFING Standard No Score 27 x 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 x x x x x x x x Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement Pre admission assessments undertaken by the home must include risk analysis (Previous timescale 30/04/05 not met) Resident care plans must contain all information with regards individual care needs and how these will be met (Previous timescale 30/04/05 not met) Residents and care staff must be involved in the care planing process (Previous timescale 30/04/05 not met) Care plans and risk assessments must be reviewed on a monthly basis and involve the resident (Previous timescale 30/06/05 not met) Any alterations to care plans or documentation must be recorded clearly and be signed by the person making the amendment (Previous timescale 30/06/05 nt met) Residentws must be consulted about their social interests, and arrangements made to enable them to engage in local, social and community based activities. Timescale for action 30th September 2005 on going 30th September 2005 on going 30th September 2005 on going 30th September 2005 on going 30th September 2005 on going 28th October 2005 on going 2. 7 15 3. 7 15 4. 7 15 5. 7 15 6. 12 16 Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 22 7. 16 17 8. 8 12 9. 10. 11. 19 19 19 16 23 13 12. 19 13 13. 19 16 14. 19 23 15. 16. 19 19 13 13 17. 19 23 A record must be kept of all complaints made and must include details of the investigation process and any action taken. Robust procedures for responding to suspicion or evidence of abuse or neglect must be in place and at all times strictly adhered to. Carpeting on downstairs corridors and lounge areas must be deep cleaned or replaced. The 3 bedrooms identified to the deputy manager must be redecorated. All continence and toilet products being stored in the downstairs bathroom must be removed to a suitable storage area. An appropriate door plate must be fixed to the carpet edge leading into the downstairs bathroom. An audit of all rooms containing commodes must be undertaken. Where those commodes are rusty or unsuitable for use they must be replaced. The light fitting that has been removed from the hallway must be replaced with a suitable fitting. The rotary iron being stored on the upstairs landing must be removed to a suitable place. Locks fitted to bedroom doors must be able to be overriden using a master key. If this cannot be arranged then alternative, suitable locks must be fitted. The barge boards identified to the deputy manager must be replaced. 30th September 2005 on going 30th September 2005 on going 28th October 2005 25th November 2005 30th September 2005 30th September 2005 28th October 2005 30th September 2005 30th September 2005 25th November 2005 25th November 2005 Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 23 18. 19 23 19. 20 23 20. 24 16 21. 25 13 22. 26 16 23. 28 18 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 (Previous timescale not met 30/06/05) A full audit of all rooms must be undertaken to ensure that issues regarding health and safety are addressed and a programme of repairs with timescales must be maintained. The hot water system must be checked by a suitably qualified person to ensure hot water emission is close to 44 degrees C throughout the home. The carpet in the bedroom identified to the deputy manager that had a strong odour of urine must be replaced. Staff must receive training that is relevant to their work role. The registered manager must ensure that staff files contain information/documentation as required in Schedule 2 of the Care Home Regulations 2001 (Previous timescale 30/04/05 not met). The registered manager must ensure that all staff have an assessment of their training needs. All staff must receive training that is linked to achieving the aims of the home and meeting residents needs (Previous timescale 30/04/05 not met) 31st March 2006 31st March 2006 28th October 2005 on going 30th September 2005 28th October 2005 28th October 2005 on going 28th October 2005 24. 29 19 25. 30 24 28th October 2005 on going Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 24 26. 33 24 27. 36 18 28. 37 17 A system of quality assurance/monitoring must be implemented, based on seeking the views of residents and other interested parties (Previous timescale not met 30/04/05) Staff must receive formal supervision at least six times per year. This must be recorded and a copy maintained on the staff members file (Previous timescale not met 30/04/05) Records required by regulation 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. 30th December 2005 on going 30th September 2005 25th November 2005 on going RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations No recommendations have been made during this inspection. Carrickfinn F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 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 F55 F05 s21539 Carrickfinn v246121 D260805 Stage 4.doc Version 1.40 Page 26 - 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. 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