Inspection on 06/12/05 for Carrwood House

This inspection was carried out on 6th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carrwood House 25/08/07

Carrwood House 26/08/06

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 Marina Warwicker Unannounced Inspection 6th December 2005 1:00 Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 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.V268270.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V268270.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Carrwood House Address 344 Grimesthorpe Road Sheffield South Yorkshire S4 7EW 0114 243 9808 0114 261 8223 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.V268270.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 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 those with relating mental illness. The accommodation comprises of ground floor communal areas and first floor residents bedrooms, bathrooms and toilets. The residents at the home socialise with those residents who live in supported accommodation i.e. the cottages and the flats. The philosophy of the home is to encourage residents to make choices, take risk as part of life style under supervision and build their self-esteem in a safe and caring environment. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Carrwood House Care home was carried out on 6th December 2005 between 1.00 pm and 4.30pm. The inspector toured the premise with the manager and spoke with service users and staff on duty. The inspector observed the interaction between staff and the service users. This is the second statutory inspection for this year and it is important that this report is read in conjunction with the last report to get an overview of this service. What the service does well: What has improved since the last inspection? What they could do better: Records and record keeping at the home need to improve. This is the basis of the requirements made. The manager should also make provision for the care staff to be innovative and take responsibility, so that they are able to take ownership for the improvements made. This will help sustain the changes made at the home. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 6 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. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 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.V268270.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&4 There is a statement of purpose and service user guide outlining the facilities at the home. The prospective service users have opportunities to visit the home to establish their suitability. Unplanned admissions are avoided. EVIDENCE: The manager and her staff have revised the documentation, which provides prospective users of the service the aims, the philosophies and the facilities available at the home. The manager discussed with the inspector how they were preparing for a new admission and the measures the staff were taking for a smooth transition. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Person Centred care plans are being introduced. EVIDENCE: The staff said that the care plans have been reviewed and changes had been made to them. They said that an external agency was helping them with implementing a Person Centred approach to care. Sample care plans will be inspected on the next visit and staffs’ understanding of the Person Centred approach will also be checked. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 The staff continue to help service users develop and maintain social, emotional and communication skills, thereby contributing to the service users’ independent living skills. The staff encourage residents to maintain links with family and friends. They enable residents to develop friendships within and outside of the home. Daily routines and house rules promote individual choice and freedom of movement. Such arrangements help the residents to live responsibly in a safe environment. The residents are offered a varied diet. This is to help the residents’ health and well-being. EVIDENCE: Staff knocked on the door and asked for permission before entering the bedrooms of service users. Those who were in their bedrooms kept their doors locked. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 11 The inspector saw the residents having tea. There was a choice of meals available for the residents. There were records of nutritional assessments on three residents’ records checked. The staff were helping and encouraging the residents to eat at teatimes. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 & 21 The staff continue to provide sensitive and flexible personal care to maximise the residents’ privacy, dignity and independence. The staff also facilitate residents, who have the capacity, to take control of their health care needs. Medication storage, handling and administration need attention by the supplying pharmacist. The staff are able to deal with terminal illness, ageing and death of service users; sensitively and respectfully. EVIDENCE: The inspector observed the staff being sensitive to the residents’ preferences when supporting them. The staff said that they had access to the contact telephone numbers for the dentist, opticians, chiropodist and primary care team. However these numbers were not recorded in the individual residents’ files. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 13 The inspector checked compliance of medication management. There were no risk assessments to confirm that the service users did not have the capacity to self medicate. There was no documentation in the care plan to indicate that the service users or their representatives had consented to medication. The inspector contacted the supplying pharmacist for the second time on 06/12/05 and requested an audit of the medication supplied to the home by her. She spoke with the manager and agreed to carry out an audit the following day i.e. 07/12/05. The home’s manager has agreed to fax the report to the CSCI following the audit. Three Medication administration sheets were checked for any gaps and they were satisfactory. Since the residents are not always co-operative and sometimes unpredictable the inspector suggested the following: That the medication records have photographs of the service users and a record of any allergies they are known to have in front of the Medication administration Records (MAR). This system helps staff to be proactive against administering incorrect medication to service users. There had not been any progress made in this area since August 2005. The staff need to be aware why each resident is on the specific medication and the precise side effects they should be observing for. The staff said that this information would be valuable. The Inspector offered some help with the format for the medication information and suggested that the staff kept this information with the medication administration sheets. Time scale for the completion of these records have been agreed by the manager to be Thursday January 5 th 2006. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has a complaint policy and recording facility for any complaints made. EVIDENCE: The manager assured the inspector that there had not been any complaints about the service or the staff since the last inspection. Some staff have attended training on adult protection and dealing with abuse situations. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The premise is suitable for its stated purpose. It is accessible and reasonably maintained. Each service user is provided with suitable accommodation. Some rooms are shared by residents. The residents are able to maintain a comfortable life style. EVIDENCE: On the day of inspection the home looked comfortable, clean and was free from offensive odour. The furnishings and fittings were compatible with the home’s stated purpose. The staff said that all service users were offered rooms to suit their individual needs. The service users only shared rooms if they preferred to do so. There were communal areas for the residents and they were safe and were in use. The present service users do not require aids, adaptations or equipment to help with their independence. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The staff at the home had defined roles and responsibilities. The staff have qualities and competencies to support the service users. On the day of inspection there were adequate numbers of staff on duty to support the residents. The manager operates a recruitment procedure based on equal opportunities and protection of service users. The home has a training and development programme. Staff receive support and supervision from the manager in order to carry out their jobs. EVIDENCE: During the inspection the staff demonstrated that they were committed to maintaining the well-being of the service users. The manager said that eleven staff out of sixteen had completed NVQ Level 2 in care. This took them up to 65 of trained staff working at the home. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 17 The manager said that since the last inspection they had received Investors in people award. The manager and her staff were proud of this achievement. Three staff recruitment and training files were checked. Although they were of a reasonable standard not enough progress has been made since the last inspection. The areas for improvement were discussed with the manager. There were records of staff having supervision meetings. The manager said that as far as she was aware the overall financial viability and effective accountability of the home was the responsibility of the owner and that it was satisfactory. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): A registered manager is in post. There is a commitment to equal opportunity in the organisation. The records required by the regulation for the protection of service users and staff are kept by the home. The staff are trained in safe working practices. EVIDENCE: The manager communicated well with the staff and residents. The manager hopes to complete NVQ Level 4 in management by April 2006. The hot water temperature at the point where service users have access needs to be recorded regularly. The last record was on 28/10/05 some six weeks ago. The manager was in agreement that this should be done each month. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 19 The weekly fire alarm test had not been carried out approximately five weeks. Therefore, the inspector instructed the manager that a test be carried out whilst she was at the premise. This was completed on the day. The fire safety training for staff needs to be formalised and the home needs to maintain a record of the areas that had been covered by the training. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 N/A 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carrwood House Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 X X X 2 3 DS0000002945.V268270.R01.S.doc Version 5.0 Page 21 YES 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 2 Standard YA34 YA42 Regulation 19, Schedule 2 13 Requirement All staff files must contain all of the information required by the regulation and the schedule. The water temperature at the point of service user contact must be checked regularly and records of the temperature must be kept for inspection. Immediate requirement made. All staff must attend formal fire safety training. There must be documentary evidence of the contents of the training. Fire alarms must be tested at a regular interval using all the fire points in rotation. Immediate. The manager must ensure that the persons employed at the home receive training appropriate to the work they are to perform. The manager must be able to show evidence of staff training at the request of the CSCI inspector. The service users’ consent to medication must be recorded in the individual care plans. Timescale for action 10/10/05 23/08/05 3 YA42 13 27/01/06 4 YA42 13,17 06/12/05 5 YA35YA42 18,17 27/01/06 6 YA20 12 27/01/06 Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 22 7 YA20 13 8 YA19YA41 13,17 The registered manager must continue to seek information and advice from the supplying pharmacist regarding the medicines dispensed for the individuals at the home. The individual’s care plans must contain the contact details of the professionals involved in their care. E.g. dentist, optician, community nurse, chiropodist, dietician. 27/01/06 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA37 YA20 Good Practice Recommendations The manager should complete NVQ level 4 in care and management qualification. The care staff must be trained and be able to access the basic information on why each service users were on certain medicines and how to recognise and deal with related problems. Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Carrwood House DS0000002945.V268270.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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