Inspection on 06/12/06 for Carrickfinn

This inspection was carried out on 6th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 02/02/06

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 John Oliver Unannounced Inspection 6 December 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.V298808.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 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.V298808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 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. The range of accommodation fees charged was between: £358:09 and £373:54 Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Carrickfinn included an unannounced site visit as part of the inspection process. The inspection was carried out over a period of six hours during which, time was spent talking to the registered manager, deputy manager, staff and several residents. Documents including staff files, records and other relevant documentation were also examined. Information was also obtained from documentation held on file at the offices of the Commission for Social Care Inspection. Other information was taken from the pre inspection questionnaire completed by the manager prior to the inspection visit taking place and 5 questionnaires returned by residents currently living in Carrickfinn. A tour of the building was conducted to make sure the home was safe and that the people receiving a service were provided with a homely and comfortable place in which to live. The inspection report from the visit carried out in February 2006 highlighted a number of areas that the home needed to work on and improve. These areas were found to have been addressed. Nationally, during a two-week period the Commission for Social Care Inspection required all key inspections of residential homes providing services to older people to look at certain National Minimum Standards (NMS 1,2,3 and 16). These standards relate to the theme of quality of the information given to prospective residents and the contract and terms of conditions provided. The theme also looked at the provision of assessments of residents’ needs before they came to live at the home and whether they had been provided with information about how to raise their concerns and make a complaint. To enable these NMS to be assessed, relevant files and documentation were seen and discussions held with the manager, staff, and where possible, residents. The outcome of the findings has been recorded in the main body of the report. What the service does well: The management and staff team of the home had continued to work hard to provide residents with a comfortable place to live. Watching the managers and staff interacting with the residents and visitors to the home gave a good indication that people living in the home felt comfortable with the staff team. Comments from residents living in the home included: Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 6 * * * * * * * “Staff are great” and “very caring”. “I get my tablets – morning and night”. “I enjoy the activities with the activity lady”, “keeps your mind ticking over”. “My family come and visit with my grandchildren”. “Food is number 1” “I am quite happy here – staff are very good – ring the bell and the staff come”. “I get on with all staff quite well – everybody tries their best – make sure you are ok and help you”. What has improved since the last inspection? What they could do better: Risk assessments did not contain sufficient details to enable staff to clearly understand how support should be offered to the individual resident to manage the identified risk. Recruitment practices needed to improve in order to make sure only suitable people were employed to work in the home. It is important that residents and prospective residents have up to date information about the home at all times. Although the home had a Service User Guide (SUG) in place, not all information was correct and some information (such as costs) had not been included. All complaints received by the home were recorded in a ‘complaints log’. It is recommended that this ‘log’ be reviewed to ensure all information is recorded in the same way. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 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 DS0000021539.V298808.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 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 the following standard(s): 1,2,3 and 6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Limited information was available to inform prospective residents about the home. People’s needs were assessed before admission into the home and arrangements confirmed by the provision of a contract. EVIDENCE: The home had a Service User Guide (SUG) and a copy was provided. This contained information about the home that was easily understood. However, some information such as how much it costs to live in the home has not been included. It is recommended that the guide be reviewed and updated to include such information as this would be important to anyone considering coming to live in Carrickfinn. The manager said that a copy of this guide and other relevant information was placed in a file in each resident’s bedroom and this was confirmed during a tour of the premises. This gives a good opportunity for the resident or the family to ask any questions or raise any concerns they may have. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 10 When asked about the costs of their care those residents spoken to were unsure of the details, however, one resident said “I think I remember getting a letter in April from Mary (manager)”. The manager confirmed this and further discussion indicated that this letter was sent to all residents in April each year confirming any increase in costs/charges over the next twelve months. On those files examined, contract arrangements/increase in fees information and breakdown of finances were available. When asked, the same residents were unsure whether they had received a contract and one said, “I think I got one”. Further discussion with the manager about contact arrangements for individual residents confirmed that the majority of the residents were funded through purchasing authorities such as the Local Authority and Primary Care Trusts. Where this is the case, then the contract is between the resident and the authority and not with the home itself. The home is paid in full by the authority and not by the resident. Files seen indicated that pre-admission assessments had been carried out for two of the three residents. However, the third resident had lived in the home for over 13 years so this information may have been stored elsewhere. Information included care management assessments as well as pre-admission assessments carried out by the home. When asked did anyone talk to them to find out what their needs were before they moved into the home one resident said, “I can’t remember”, the other, “I think someone did”. Wherever possible, prospective residents and their family/representative were encouraged to view the home prior to making any decisions about admission. The home did not provide an intermediate care service. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 11 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): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The on going health care needs of residents had been identified and were being met although further work was required to ensure consistency in the systems used. Medication policies and procedures were being adhered to. EVIDENCE: Care plans had been developed for all residents living in the home using the information gathered from care management assessments and the homes own pre admission assessment documentation. Of those care plans examined, details appeared to be comprehensive and evidence that monthly reviews had been carried out was seen. However, information was not consistent in all files examined and a number of risk assessments did not clearly define how the identified risk was to be managed. One example of this was, where a resident had been assessed with mobility difficulties, the information available did not detail the assistance required. Lack of such important information could place the resident at risk of their identified needs not being appropriately met. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 12 Although the manager stated that residents had been invited to participate in the formatting and reviewing of their care plans, most had declined to do this. Wherever possible, care plans should 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. During the visit other health care professionals were seen to visit the home including a doctor who had visited in order to carry out a review of each patient living in the home. Observation of the interaction between staff and residents during the course of the inspection visit 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. Of the 5 questionnaires returned to the Commission for Social Care Inspection by residents living in the home, comments about staff included: “staff are great” and “very caring”. Medication was administered via a Monitored Dosage System and the manager confirmed that all staff with the responsibility for administering medication had received appropriate training with further training planned for the near future. Since the last inspection visit in February 2006 the home had changed the supplying pharmacy and the deputy manager said that the service received was very good. Medication was stored in a locked trolley that was anchored to the wall in the dining room. Medication Administration Records (MAR) were examined and were found to be appropriately completed. Records were kept of medication received into the home as well as records being kept of medication disposed of/returned to the pharmacy. Medication to be given “as and when required” was clearly identified and a record was maintained of balances of this medication to ensure a clear ‘audit trail’ was readily available. A spot check of a number of balances was made and was found to be correct. One resident spoken to about medication said, “I get my tablets – morning and night”. Prescriptions were collected directly from the surgery by the pharmacy. This would mean that if a prescription had been completed incorrectly the home would be unaware of this, which could place the resident at risk. It is strongly recommended that all prescriptions be received by the home before being sent to the pharmacy for dispensing. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: Since the last inspection visit conducted in February 2006 the home had employed an ‘activities organiser’ with specific responsibilities for this role. Evidence was available to show that activities were planned in consultation with residents and records had been kept of those activities that had taken place. Of the 5 questionnaires returned to the Commission by residents living in the home 4 stated that activities ‘always’ took place and one stated ‘usually’. Discussion with a number of residents also confirmed that activities were now available in the home on a regular basis and, that these activities were what residents wanted to do. Residents had participated in developing a ‘themed window’ in the lounge area of the home and were involved in ‘dressing’ the window for special occasions such as Halloween, bonfire night and, at the time of this visit, Christmas. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 14 Other events had been arranged for the holiday season including a visiting Steele band. No restrictions were placed on visitors coming to the home and the visitor’s book indicated that a number of residents had frequent visitors. Residents spoken to about activities and visitors offered the following comments: “I enjoy the activities with the activity lady”, “keeps your mind ticking over”, “Went to Blackpool – saw the lights” and, “My family come and visit with my grandchildren”. Menus were planned in consultation with residents using a four weekly menu cycle. Two main choices were available each day and the cook asked residents individually what their preferred choice was. Questionnaires returned to the Commission confirmed that those residents were happy with the meals provided and one resident said that: “the food is lovely – you get a good choice”. Discussion with the manager confirmed that nutritional assessments were carried out on admission into the home and then reviewed and monitored on a regular basis. Evidence was available to demonstrate that one resident who could suffer with high cholesterol had an individual ‘healthy option’ menu available to them at any time. Further discussion with the manager confirmed that any resident could choose from the ‘healthy option’ menu if they preferred. Residents spoken to about meals offered the following comments: “Food is number 1” and “I’m on a special diet – the cook knows”. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had relevant policies, procedures and systems in place to enable concerns to be raised and to protect residents from neglect and/or abuse. EVIDENCE: As identified in the last inspection report, the home had a complaint procedure, which was also included in the Service User Guide. However, it is recommended that the information be reviewed and further updated to identify timescales for responding to any complaints raised. Three residents who had lived in Carrickfinn for varying lengths of time were asked had they been given a copy of the homes complaints procedure and did they feel they had enough information to make a complaint about their care should they need to? One resident said “I can’t remember” and another said “No”. The third resident did not participate. Evidence seen demonstrated that the complaints procedure was made available to each resident within the service user guide, which was available in each resident’s bedroom. Further discussion with both residents confirmed that they would “go to Mary (manager)” if they had a concern or complaint. Of the 5 questionnaires returned to the Commission, 4 stated that the resident ‘always’ knew how to make a complaint, and, 1 ‘usually’. Examination of the Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 16 complaints records kept by the home indicated that one complaint had been recorded since the last inspection visit and that this had been appropriately dealt with. However, it is recommended that the format used to record the details of complaints be reviewed. This should be done in order to clearly demonstrate the processes used during the investigation of a complaint e.g. the nature of the complaint, the investigation process, the outcome, the conclusion, and, the signature and date of the manager. The home had a detailed policy and procedure relating to the protection of vulnerable adults, including the Local Authority’s multi-agency procedure ‘No Secrets’. Discussion with the manager confirmed that no allegations of abuse had been made or referred since the last inspection visit in February 2006. Further discussion with both the manager and deputy manager demonstrated that they were both clear about the procedure to follow in the event of an allegation of abuse being made etc. Staff spoken to confirmed that they had received training in the ‘Safe Handling of Vulnerable Adults’. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general environment of the home was clean, tidy and comfortable with systems in place to protect the safety of the residents. EVIDENCE: Since the last inspection visit conducted in February 2006 the management team of the home had made considerable efforts in meeting the requirements made and improving the physical appearance of the home for the added comfort of the residents. The manager had carried out an audit of the standard of furnishings and decoration of all bedrooms in November and a record was kept. A number of bedrooms had been redecorated and had new furniture supplied, along with new commodes and, new floor covering. Rooms had been personalised and reflected the character of the individual resident. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 18 The lounge area was appropriately furnished and had recently been redecorated and repainted along with the dining area. New floor covering that had been laid had further enhanced the dining area. This new floor covering reduced the risk to residents from slips, trips and falls. At the last visit to the home much of the external woodwork of the premises was in poor condition. Window frames were rotting in places and the bargeboards around the roofline were showing signs of wear and posed risks to both residents and staff. Since that visit both the internal and external appearance of the home had been much improved by the fitting of new UPVC double-glazing throughout. Other maintenance work to the premises had also been carried out including the re-surfacing of the flat roof and re-tiling to the front elevation of the home. The rear garden was well maintained and two new sets of good quality garden furniture had been purchased to ensure that resident’s could enjoy any nice weather in comfort. Part of the refurbishment programme for the home was the proposed installation of a new UPVC conservatory (which was on order) subject to planning approval being received from the local authority. If the plans were approved the installation of this conservatory would provide a smoke free area for the comfort of those residents in the home who do not smoke. Improvements to the kitchen area of the home had also been made which included the fitting of new flooring covering, the installation of a new ‘double range’ gas cooker, and the purchase of a new microwave. A recent visit to the home by an officer from the Environmental Health Department indicated that no concerns had been raised and that no further visits were planned. No unpleasant odours were detected during a tour of the premises and those areas seen were clean, tidy and pleasantly furnished. Bacterial hand wash and paper towels had been provided in toilets, the kitchen and the laundry area. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment and training policies and procedures in place were not being fully adhered to leading to potential for residents to be put at risk. EVIDENCE: Discussion with the manager confirmed that two new members of staff had been employed in the home since the last inspection visit in February 2006. Both people had previously been employed in another ‘local’ care home that had closed down. Information on their files included an application form, a contract of employment, a training record, accident records and a Criminal Record Bureau (CRB) en-hanced check. However, examination of the CRB confirmed that this had been brought with them from their previous place of employment. When this was discussed with both the manager and deputy manager both stated that they understood CRB’s were transferable within jobs of the same nature as long as there had been ‘no gaps’ in the employment and as long as a new CRB had been requested at the start of the new employment. It was made clear to both managers that CRB’s were not transferable in such circumstances. It is important that CRB’s are requested and received back before any new member of staff commences work to ensure that residents are safeguarded by employment procedures used by the home. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 20 Staffing rotas indicated that enough staff were on duty at any one time to meet the needs of those residents living in the home and the manager confirmed this. However, discussion with staff highlighted that, at times, it would be helpful to have more staff on duty. It is recommended that staff discuss such issues with the management team to ensure that residents needs are met in the most appropriate way at all times. Staffing was discussed with two residents who offered the following comments: “I am quite happy here – staff are very good – ring the bell and the staff come”, and, “I get on with all staff quite well – everybody tries their best – make sure you are ok and help you”. 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. National Vocational Qualification training (NVQ) Level II had been successfully completed by 8 members of the care staff team. Comments from staff regarding training included: “Plenty of training is made available” and “The deputy makes sure we get opportunities for training”. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 21 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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run in the best interest of residents. EVIDENCE: The registered manager had the necessary experience to manage the home and, as she has been in post for a number of years, knew the residents very well. Since the inspection visit carried out in February 2006 the manager confirmed that she had received training in the following: First Aid, Basic Food Hygiene, Health & Safety, Dementia, Moving and Handling and the Protection of Vulnerable Adults. One member of staff spoken to said: “You couldn’t wish for a better manager” and observing the interaction between the manager and the residents and staff Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 22 in the home demonstrated that relationships were positive and that the manager and deputy manager were approachable. 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. Examination of a number of questionnaires completed by residents demonstrated that the management team had considered asking questions that were appropriate to the lifestyle in the home e.g. “Do you know where to find the complaint procedure, service users guide and your personal care guide?” “Do the staff listen to you?”, “Do you feel the staff meet your needs?”, “Do you feel you get enough to eat?” and, “Do you have any input into your care planning?” However, it is recommended that questionnaires be dated and following receipt of completed questionnaires, the management team should review the answers to the questions asked and develop an action plan to address any particular issues raised or to further develop the service offered by Carrickfinn. Discussion with the manager confirmed that the registered provider (owner) of the home visited every Tuesday and Friday and spent time talking with the residents and staff. Evidence of the improvements seen in the home since the last inspection visit in February 2006 demonstrated that the registered provider had addressed important issues raised in the report. It is recommended however that the registered provider complete a brief monthly report to further demonstrate the input they provide to the home and the support offered to the management team. A copy of which should be available in the home. Where the home supported residents to maintain their personal allowance records were kept of monies spent with receipts obtained. Each resident had a small safe in their bedroom in which they could put small personal items of value etc. The manager had provided the Commission with a completed pre-inspection questionnaire prior to the visit taking place. Information contained within this document confirmed that the maintenance of equipment had taken place on a regular basis and a random selection of records examined during the visit confirmed this. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement Risk assessments must clearly identify the assessed risk and must also clearly define how the risk is to be managed. New staff must not commence working in the home until all required pre-employment checks have been successfully completed. Timescale for action 31/01/07 2. OP29 19 31/01/07 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 OP1 Good Practice Recommendations It is strongly recommended that the current Service User Guide be reviewed and updated to ensure that all relevant information is available to current and prospective residents. It is recommended that care plans be signed by the residents and/or their representative to show their involvement in the process. It is strongly recommended that any prescriptions are seen and checked by the home before they are sent to the DS0000021539.V298808.R01.S.doc Version 5.2 Page 25 2 3 OP7 OP9 Carrickfinn 4 5 OP16 OP27 pharmacy for dispensing, It is recommended that the format used to record complaints be reviewed in accordance with the details in the main body of this report. It is strongly recommended that when staff feels more staff may be required to be on duty then this should be brought to the attention of management. Carrickfinn DS0000021539.V298808.R01.S.doc Version 5.2 Page 26 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.V298808.R01.S.doc Version 5.2 Page 27 - 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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