Inspection on 25/08/07 for Carrwood House

This inspection was carried out on 25th August 2007.

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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carrwood House 26/08/06

Carrwood House 06/12/05

Carrwood House 15/03/05

Carrwood House 31/08/04

Carrwood House 05/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Carrwood House 344 Grimesthorpe Road Sheffield South Yorkshire S4 7EW Lead Inspector Stephanie Kenning Key Unannounced Inspection 25th August 2007 09:00 Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 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 Carrwood House DS0000002945.V337272.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 Adults 18-65. 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. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carrwood House Address 344 Grimesthorpe Road Sheffield South Yorkshire S4 7EW 0114 243 9808 0114 242 0813 none 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) Mr Frederick Marshall Mrs Julie Marshall Ms Mabel Ann Hudson Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th August 2006 Brief Description of the Service: Carrwood House is a registered care home offering personal care and support to adults (between the ages of 18 - 65 years) with learning difficulties and some service users with relating mental illness. The accommodation comprises of ground floor communal areas and first floor service user bedrooms, bathrooms and toilets. The philosophy of the home is to encourage service users to make choices, take risk as part of life style under supervision and build their self-esteem in a safe and caring environment. The gardens are landscaped and there are car-parking facilities. Copies of the last Commission for Social Care inspection report was available for service users and their families to read. The weekly fees range from: £339 to £450.76. This information was provided on the 20th September 2007. The home charges extra for chiropody, toiletries, clothing and holidays. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit primarily took place on 25th August from about 9am to 5:15pm and on 30th August from 9:30 to 1:30. On the first visit the lead pharmacy inspector Steve Baker accompanied Stephanie Kenning during the morning. Later that day an incident occurred at the home that restricted the inspection and Ms kenning returned for the second visit to complete the inspection. As part of the inspection process the inspectors spoke to twelve service users, two relatives, five staff and the manager. A management consultant was also present on both occasions. The inspectors would like to thank service users, relatives, the staff and the management for their openness and for their commitment to the inspection process. The inspectors were pleased to note that all service users spoke positively of the ongoing support provided by the staff. Observations confirmed that service users were extremely comfortable and at ease in the company of the staff whom they said were approachable, supportive and sensitive to their needs and feelings. A number of records were examined which included, the Annual Quality Assurance Assessment completed by the manager, 9 service users surveys, medication records, three service users care plans, two staff records, accident records and staff rotas. Records relating to service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Feedback on the inspection was given to the manager before the inspectors left the home. No complaints have been received about this home since the last inspection. What the service does well: The environment is homely, friendly and welcoming. Staff interacted well with each service user and it was obvious from discussions with the service users that staff had developed positive relationships with them. Service users said the staff team and the care that they received were good, and that the manager was approachable and very helpful. The staff said they were keen to ensure they meet the diverse needs of service users and gave some examples, such as providing entertainment in another language. The breakfasts and lunches offered to service users were of good quality, well presented and a good choice of food was offered. Service users said they loved the food that was well cooked and that other choices were always provided if they wanted them. Documentation and discussion with staff showed that they have had training in the specialist area of work that they work in and 100 had obtained an NVQ level 2 (or above) in care, showing the commitment to training and improving the service. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standard 2 A full needs assessment is made available before admission to establish if the home can meet that persons needs. EVIDENCE: People living at the home are usually placed through the care management system, and as such are assessed prior to their placement with a copy held at the home. In addition, the home does their own assessment of needs that links to the new care plans seen in peoples’ records. These were clear and met peoples’ basic needs in terms of support for daily living tasks. They were focussed on individuals needs and there was some evidence through signatures in the records that people using the service had been involved in the assessment and care planning process. There was an example of identifying the cultural needs of an individual that was then supported by an activity that was enjoyed by a group of service users. Not all service users had the new style documentation in place. In discussions with the people using the service there were several people who wanted more from life, such as a job, a purpose in life, a regular wage, and more independence. Person centred plans were Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 9 being introduced at the home and this should help to identify peoples aspirations and goals, and to plan realistic steps forward towards those goals. Staff working at the home knew the service users well, demonstrated good relationships with them, and were praised by the people living at the home for the support that they offered. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 6,7,9 A new care planning system is being introduced that clearly shows the needs and preferences of people using the service and how staff can support them. EVIDENCE: Three care plans were looked at in detail, and were checked against what the service users and staff were saying. This helped to give a clear indication if the care plans were up to date and accurate. During the past few months the care plan documentation has been changed and improved to be relevant to the service users. They include an assessment and a plan of action linked to each area identified such as personal hygiene, medication, living and domestic skills, activities, independence, and communication. Two of the care plans were in the new format and were much clearer and more accurate, and showed that the support given was appropriate. They detailed exactly what the service user could do and what the staff member needed to do to support Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 11 them. They showed personal preferences, abilities and limitations, and were signed by the service user that demonstrates their individuality and the involvement of the service user. There was clear information about communication issues such as language, accents and which people they relate to well. The bits that were missing were the aspirations and goals that each service user wants to aim for, and which several of them raised during the inspection. These were, wanting a job, wanting to do something purposeful in life, wanting to be independent, wanting a wage every week. The person centred plans being introduced at the home should identify these goals and aspirations and plan a way forward towards meeting them, but they are not in place yet. Information about health was recorded, and the records showed attendance at a range of medical appointments, including dentist, GP and hospital, showing that consideration is given to health issues. More comprehensive health assessments were being introduced at the home, but had not been completed fully for the people whose documentation was looked at. The care plan that was of the old style did not give sufficient information about things like activities, preferences, communication issues, and should be improved as soon as possible. It was stated that the changing of the documentation was taking longer than expected and it was better to do it properly than to rush and make mistakes. Risk assessments had been reviewed, and were signed by the service user, and staff members were aware of them. An example relating to the smoking habits of an individual gave unrealistic actions for that service user, (despite agreeing to it on paper), and was not therefore accurate. It would be better to review this and amend the actions to take in order to ensure the risks are lowered, and therefore improve the safety of all at the home. This was discussed during the visit and the manager agreed to review it. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 12, 13, 15, 16, 17. Improvements have been made to the range of activities and opportunities available, however, there are several service users that are not feeling fulfilled and are frustrated. The home is limited in its resources to provide some of these opportunities, for example independent living skills development. EVIDENCE: There have been a range of different activities organised for individuals and groups to participate in all of which were praised by service users as good. For example there have been musical evenings, quizzes, an Indian night, visits to events at the university and a multi-cultural centre, walks, countryside visits, shopping, meals out and gardening. Two people attend a day care centre one day each week and also a gardening group. Some people have hobbies or interests that they pursue such as watching sport on TV or meeting friends. Each person does some degree of domestic tasks such as keeping their room Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 13 tidy, and staff support when necessary. Work on certain independent skills, such as managing monies and using transport was observed. There is no facility available for helping people learn to cook or prepare meals for themselves, in preparation for more independent living. There was some evidence of staff seeking information for service users regarding access to education and employment, but they felt that there were limited opportunities available for the people living at the home. Management and key-workers also stated that as they were identifying more aspirations of the service users, their limited resources of staff and finance were limiting their ability to seek out better opportunities for service users. Without more input some service users said they were bored, and were observed spending time pacing up and down or asleep, whilst others ended up in the pub for the afternoon, and could cause disruption on their return. Two relatives commented that the home welcomed them and involved them in events at the home. They praised the manager and staff for their support of their relatives and felt they did a good job. Relationships between service users were generally okay, but several people felt that the behaviour of other service users was difficult to live with all the time. Many people share rooms at this home and some felt that it was sometimes difficult to be private and get away from other people. The meals provided were highly praised by service users who felt that they had both sufficient amounts of food and a choice at each meal. They were able to make suggestions for the menu, and some interesting foods were also offered such as at the Indian night. Salads and fruit were available on request. Whilst several people wanted to be more independent they did like being catered for. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 18,19, 20. People’ individual personal and healthcare needs are met, however, some aspects of medication procedures are not safe. EVIDENCE: Generally people living at the home were supported in their personal care, as they wanted, for example being prompted to be independent in personal hygiene. Service users appreciated the support offered by staff and most felt that their wellbeing had improved since being at the home. One area of concern was the lack of privacy in the shared bedrooms, with no screens to use whilst washing or undressing. The management of the home were aware of this and were struggling to find a safe and aesthetically pleasing solution. People living in this home had a broad range of health care needs as well as the learning disabilities and mental health issues that led them to a place at the home. Information about health was recorded, and the records showed attendance at a range of medical appointments, including dentist, GP and Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 15 hospital, showing that access to health care is available. More comprehensive health action plans were being introduced at the home, but had not been completed fully for the people whose documentation was looked at. Once completed these may help to identify further heath care support needed, and alert staff to certain triggers regarding health that they will be able to respond to. The home has a medication policy which is accessible to staff but is need of some revision and expansion. Medication records are generally up to date and medicines received, administered and disposed of are recorded. Medication administration processes do not always follow safe practice guidelines. Medicines are not currently stored under optimum conditions and improvements in security and storage environment are recommended. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 22, 23 People using this service knew how to raise their concerns, and could identify which person they would approach. The records relating to service user monies were not always clear, which has the potential for errors. EVIDENCE: There had been no complaints at the home since the previous inspection. People living at the home generally knew how to make a complaint or identified someone who could help them raise their concerns. An advocacy project at the home had ended, but it had increased awareness of the rights of service users to have a voice about their lives, and management at the home were hoping to build on this and to try to enlist more advocates. Where possible social workers were kept involved, and one person was being offered weekly support. Staff have had training in adult protection procedures and managing challenging behaviour, and could explain about how they protect service users from abuse. Some people living at the home were concerned about the behaviour of others at the home, but had not been personally involved in any incidents. During the first visit to the home an incident occurred that involved a verbally aggressive service user and their relative. This was handled well by the staff, but it was clear how unsettling the incident could be for others living at the home. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 17 The home manages most peoples money with agreements about how this will be done and what monies the service users can access. The records of transactions are less clear and it was difficult to trace some of the purchases on the records examined, because the records were not clear enough. For example a receipt for a television was on file, but it was not obvious which entry on the log it related to, meaning this has the potential for abuse. The homes administrator audits individual accounts annually. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 24,30 There are ongoing improvements to the décor of the home with plans for more. People living in shared rooms have no privacy and they were concerned about this. The home does not offer facilities to improve independent living skills which frustrates some service users. EVIDENCE: The home is in an old listed building, which has some period features. It is registered for up to 16 people, though one room is being used as an office, limiting the numbers to 15. At the time of the visit 13 people were living at the home, and 12 were male. There are a variety of room sizes and shapes, with most bedrooms on the first floor, though some were on the ground floor accessed through the courtyard. A communal lounge and a separate dining area were also on the ground floor, and the smoking area is an external courtyard area with seating. The fire hazards in this area presented at the previous visit had been removed. There are no small group living areas, and Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 19 no facilities to aid the independence training that some of the service users were requesting. Management of the home had identified these as areas to improve on, but were struggling to find the space within the building to create them. A tour around the home demonstrated that a substantial amount of redecoration had taken place, particularly in the bedrooms, improving the appearance. The home had an audit of the building that they were using to address problem areas, and still had a list of tasks to complete. During the tour of the bedrooms it was noticed that none of the (five) shared rooms had privacy screens and this was raised by two of the service users as a concern. Management stated that the previous screens had been removed prior to the redecoration, as they felt that they were unsightly and were looking for a better solution to replace them. None of the rooms had en-suite facilities, other than a shared washbasin within the bedroom, and this means that people living in these shared rooms have to wash and undress in front of their room- mate. People living in the home do have their own door keys, unless they chose not to, and this has helped to some extent with privacy. There was some personalisation in some of the rooms, and the home was clean and comfortable. In one of the bathrooms the water coming from the hot tap had a very poor flow and did not get warm. When asked, the service users said that it had been like that for a long time, however after this was pointed out to management, a plumber arrived to fix it before the end of the visit. Work was in progress re-grouting the tiling in the shower room, and plans were in place to improve the appearance of some of the other bathrooms, which were looking shabby. The gardens are well used by the people living in the home, and some work had started to clear overgrown areas, improving the outlook for people using this facility. There is a lot of potential to add interesting features, colour and for developing the service users interest in this area. A barbeque area and seating was available for people to use when outside. Adjacent to the home is a row of cottages owned by the provider that offers independent accommodation with support, and has some links with the residential home, for example, some activities. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 32,34 35 The recruitment records show that thorough checks are made on staff before employment in order to safeguard the service users. In addition the staff team have received appropriate training to enable them to support the people living in the home. EVIDENCE: Generally there are two members of staff (including a senior) on duty at all times plus the manager and ancillary staff during the week. This was adequate for meeting basic needs, but was said to limit more in depth work with an individual. Sometimes an additional person is brought on duty for a specific task such as escorting a service user on an outing, or for a review meeting, reflecting some flexibility. Staff turnover is low with the last person recruited well over 12 months ago showing stability and continuity of service. An employment tribunal regarding the dismissal of 2 members of staff has had an unsettling effect on everyone at the home, but has now finished and they are in the process of recruiting a deputy manager and increasing care staff levels. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 21 Examples of recruitment checks were seen within staff files, and included Criminal Record Bureau Checks and references, these help to safeguard the people living in the home. Some emphasis has been put on staff training during the past year, in order to improve the service offered to people living in the home. Training has included the following, the role of the care worker, food hygiene, fire prevention, administration of oral medication, managing challenging behaviour, abuse in the care home, as well as working towards the Induction Standards and NVQs in care, where 100 of the care team were stated to have achieved level 2 or above. This is an excellent achievement and shows the commitment of the provider and manager. Staff meetings take place regularly, stated to be almost every week, and some minutes of these meetings were seen. These help to identify issues that staff are dealing with and where they may need support, information or training. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 37,39,42. The management of the home is becoming more proactive and implementing new systems and audits that will help to improve the service offered to people living in the home. There are some areas that need further work and an action plan is already being developed for the development of the service. EVIDENCE: The manager Ann Hudson has been at the home many years and therefore very familiar with all aspects of the home. She has recently obtained the NVQ level 4 and has been introducing internal audits on all aspects of the home to help her to identify problem areas as well as those doing well. She is liked by the people living in the home and was said to be approachable, making it Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 23 easier for people to take their concerns to her. The management control of the home is improving and is starting to be more proactive rather than reactive, which should improve the overall service offered to people living in the home. An example of this is the request to the placing authority for more support with a person living in the home. The manager and staff have a good awareness of individual service users, and they communicate well using daily handovers, records of daily interactions, and regular meetings. They undertake surveys of the people living in the home to establish their views, and try to incorporate the suggestions for improvements in the home. Examples that have been acted upon are new foods and activities, a television with a greater choice of channels, access to a computer under supervision, a garden group to help maintain the grounds, and a women’s’ group. There is a plan outlining improvements that the manager would like to make to the service, including improving independent living skills, and increasing opportunities for service users to access community facilities. Not all the resources are in place to achieve these improvements, though increased staffing will help with this. These improvements are necessary in order for the home to fully meet the aims they set out in their statement of purpose and in particular the one relating to fulfilment of life. The safety of people in the home is reliant on everyone following the written procedures that are available, and encouraging those who do not to act safely. There have previously been some issues regarding smoking, and a small fire incident occurred through those procedures not being followed. Since the previous visit there have been 2 accidents reported involving service users, these were dealt with appropriately and detailed records found in their personal documentation. Individual staff members reported five accidents, but there was no follow up recorded or indication that they had been noted. The manager stated that they had been dealt with and in future she would record any action taken. There are some areas noted throughout this report that management need to address to improve the service and the safety of people in the home. They include the financial records, privacy in shared rooms, ensuring that the care planning documentation is fully implemented, review and improvement of medication practices, and continuing to improve the environment. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 x Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 25 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 YA11 Regulation 16 Requirement Provide facilities for service users to prepare their own food as part of developing independent living skills. The registered person must ensure that: medicine policies & procedures are updated in line with current guidance so that staff understand how to handle & administer medicines safely; administration processes follow current best practice guidance; all medicines are stored securely away from public areas and at correct temperatures so that staff know they are safe to use. Improve the recording system to ensure clarity in service user accounts. Ensure that people living in shared rooms have facilities to be private when required. Timescale for action 31/03/08 2. YA20 13(2) 01/12/07 3. 4. YA23 YA24 17 12, 23 01/11/07 01/12/07 Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 26 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 YA20 Good Practice Recommendations Dividers displaying photographs and other essential information should separate MAR charts in the folder to enable staff to be sure they are always giving medicines to the right person. Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Carrwood House DS0000002945.V337272.R01.S.doc Version 5.2 Page 28 - 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. 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