Inspection on 28/02/06 for Cartref House

This inspection was carried out on 28th February 2006.

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

The inspector found 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

Cartref House 28/06/07

Cartref House 25/11/05

Cartref House 08/02/05

Cartref House 16/07/04

Cartref House 15/03/04

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

CARE HOME ADULTS 18-65 Cartref House Cartref House 22 London Road Sittingbourne Kent ME10 1NA Lead Inspector Gary Bartlett Announced Inspection 28th February 2006 9:30 Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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 Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cartref House Address Cartref House 22 London Road Sittingbourne Kent ME10 1NA 01795 428447 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) care@cartrefhomes.co.uk Cartref Homes UK Limited Mr Robert William Tyler Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2005 Brief Description of the Service: Cartref is a semi-detached property with accommodation on three floors, bedrooms being on the first and second floors. All rooms are single occupancy and have television points. It offers accommodation and support for 6 young adults with learning disabilities, with the emphasis on assisting them to move towards a more independent life style. Services are individually tailored to meet the needs of the service users, offering opportunities to develop their skills as is appropriate. The home is situated on the busy A2 leading into Sittingbourne, with shops and other local amenities within easy walking distance. It is on a bus route and there is a main line railway station approximately a quarter of a mile away. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in the Home from 9.30 a.m. until 1.10 pm. During that time some service users and staff were spoken with and parts of the Home and some records were inspected. The focus of the inspection was to inspect the Standards not assess at the last inspection and to assess compliance with the notified recommendations. Consequently, this report should be read in conjunction with the inspection report dated 25 November 2005. The House Manager and staff were helpful and gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? Cartref continued to review and evaluate working practice, policy and procedures to ensure the services and facilities provided were of a high standard. Parts of the Home had been redecorated. The House Manager was now involved in the recruitment of staff. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 6 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. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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 Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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 and 5 Service users interests would be better served if the Service Users Guide and contract were updated. EVIDENCE: The Statement of Purpose, Service User Guide and contract of terms and condition were a combined document. The House Manager stated that every service user had a copy. The example inspected had been issued in November 2005 but had not been updated to include the name of the Commission of Social Care Inspection. It did not include details of the room to be occupied by the service user nor had it been signed by a representative of Cartref Homes. The contract had facility for it to be signed by representatives of the service user. This had not been done, although the House Manager said the service user’s relatives had gone through the contract on their behalf. Advice was given that all parties interests would be better served if they all signed the contract. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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): 10 Information about service users is handled appropriately and confidentiality maintained. EVIDENCE: There were policies and procedures for this, of which staff had a good knowledge. Service users did not have any concerns about how staff handled information about them and the staff spoken with were aware of the need to promote confidentiality. Records were seen to be stored securely when not in use. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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): 14 and 15 Service users had access to appropriate leisure activities and enjoyed good links with their families and friends outside of the Home. EVIDENCE: The Home placed great emphasis in knowing services users’ personal interests and enabling them to pursue them. Most activities were undertaken individually but some were done in groups, for example if service users wanted to visit the cinema for the same film. The House Manager said the predominance of 1:1 activities gave service users better opportunity to “openup”. There was a budget for holidays and service users cold choose whether to take these singly or as a group. Some service users preferred long day outings rather than holidays away from the Home. Families and friends could visit the Home at any reasonable time and some service users often stayed with their families at weekends. Service users said they were happy with the arrangements and facilities for entertaining visitors. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 11 Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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 and 20 The personal needs of service users were well met and all personal care was given in privacy. Improving medication procedures would enhance the protection of service users. EVIDENCE: Staff were seen to be very good at providing personal support to service users in a sensitive manner. The way in which this was done was obviously tailored to the circumstances of the moment. Some residents were still in bed at the time of the inspection and had breakfast when they wished. This flexibility took account of planned activities, for example, whilst some service users slumbered, one was off to the gym. Where any restrictions were applied, the service users understood the necessity and considered them fair. Care plans indicated specialist support and advice was obtained when necessary. Medications were only administered by staff trained to do so. There were not any self-medication service users at the Home but the House Manager said this could be done if the necessary risk assessments indicated it was safe. The Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 13 medicines cabinet was well maintained but too small to store external medicines from internal medicines and the temperature of the medicines storage area was not being monitored. Some Medication Administration Record (MAR) sheets had been signed in pencil and there was an instance where the sheet had not been signed although daily records indicated the medication had been given. Commendably, the MAR sheets were audited weekly. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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): 23 Staff must receive training in adult protection to better promote service users’ safety. EVIDENCE: Cartref Homes had a detailed adult protection procedure and documentation. A copy of the local authority adult protection procedure was also available. The House Manager stated that all managers had undertaken a four-day “adult protection training the trainers” course but had not yet had the opportunity to train the staff. The need for this to be done was evidenced by the fact that staff had not followed the organisation’s adult protection procedures when a service user had assaulted another the previous evening. It should be noted that staff had dealt with the immediate situation well, the failings were with regard to follow-up action. All staff had attended training in non-aggressive intervention recently. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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): 24 and 30 Service users lived in a comfortable, clean and well-maintained environment. EVIDENCE: Service users said they liked the house and were able to be involved in decisions about décor. There was an ongoing programme of redecoration and refurbishment. Some repairs were needed and the House Manager said these had been notified to the maintenance person but he was shared between all of the 5 sites operated by Cartref Homes. All parts of the Home seen were commendably clean, warm and comfortable. It was observed that the Home needed to ensure that appropriate soap dispensers and hand drying facilities were provided in the laundry and all communal washing areas to promote infection control. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 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): 36 Staff received the support and supervision they needed to provide good care to service users. EVIDENCE: Staff spoke of regular supervision meetings that were minuted. These were two-way meetings at which staff could voice their own views. Staff meetings were held monthly. Staff were also monitored on a daily basis. Staff were aware of the grievance and disciplinary procedures. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 17 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): The home was well run in the best interests of service users. The health, safety and welfare of service users were promoted. It must be clear that all staff participate in regular fire drills. EVIDENCE: The House Manager described how they placed great importance of obtaining service users views about the running of the Home. In addition to the daily contact with service users, there was a meeting every 6 weeks. Services Users were asked what they wanted on the agenda in advance of the meeting. The company regularly conducted audit visits as required by Regulation 26. It was agreed that the quality monitoring systems would be enhanced by obtaining the views of service users’ families, friends and advocates. Perhaps through the use of questionnaires at regular intervals. Environmental risk assessments were regularly conducted to ensure the safety of service users. Maintenance certificates were seen to be current. The House Manager was ensuring that al staff had received food hygiene and first aid Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 18 training/updates as required. The House Manager described how they were currently establishing whether Legionalla checks were to be undertaken. Records indicated that the fire protection systems were regularly checked but did not show that all staff had participated in regular fire drills at the intervals specified by the Fire Safety Officer. The Manager described how staff and service users worked together to maintain the standard of cleanliness in the kitchen. Refrigerator and freezer temperatures were being monitored. An Environmental Health Officer had inspected the kitchen on 24th October 2005 and there had not been any matters arising. Staff were seen to be diligent in ensuring COSHH requirements were adhered to. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 19 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 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X X X 2 X X 2 X Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation Requirement Timescale for action 21/03/06 2 YA23 3 YA30 13(2),17(1) “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that: 1. Provision must be made for the seperate storage of external and internal medicines. 2. The temperature of the medicines storage area must be monitored. 3. M.A.R. sheets must be completed appropriatly. An action plan is to be received by CSCI by the given timescale. 13(6) “The registered person shall 21/03/06 make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse” in that all staff must be trained in and adhere to the adult protection procedures. An action plan is to be received by CSCI by the given timescale. 13(3) The registered person shall 21/03/06 make suitable arrangements to DS0000023921.V283796.R01.S.doc Version 5.1 Cartref House Page 21 4 YA42 23(4) prevent infection,toxic conditions and the spread of infection in the care home in that appropriate hand washing and drying facilities must be provided in all communal washing areas and the laundry. An action plan is to be received by CSCI by the given timescale. The registered person shall 21/03/06 ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life in that fire training must be provided and drills undertaken at regular intervals. This refers to all staff, including night staff. An action plan is to be received by CSCI by the given timescale. 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 YA1 YA5 Good Practice Recommendations It is recommended the Statement of Purpose and Service Users Guide be updated to include the correct name of the Commission It is recommended the Service Users Contract be updated to include the correct name of the Commission, include the room to be occupied by the service user and be signed by the representatives of the organisation and of the service user. It is recommended consideration be given to allocating more maintenance hours to the Home. It is recommended that the views of service users’ families, friends and advocates are sought on how the DS0000023921.V283796.R01.S.doc Version 5.1 Page 22 3 4 YA24 YA39 Cartref House Home is achieving goals for service users. Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Cartref House DS0000023921.V283796.R01.S.doc Version 5.1 Page 24 - 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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