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Inspection on 02/08/05 for Cartref Residential Care Home

Also see our care home review for Cartref Residential Care Home for more information

This inspection was carried out on 2nd August 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provider offers a comfortable domestic environment for the service users. The standard of care is good and works toward meeting the individual needs of service users

What has improved since the last inspection?

The service provider has continued to develop the service users` care planning process.The service provider has continued to develop plans to extend the premises to provide care for more service users.

What the care home could do better:

The service provider must apply to vary the home`s registration to describe the service user group currently resident in the home. The service provider must formalise the risk assessment of service users in order to more fully develop their independence. The service users` safety in the home must be improved by risk assessment of the accommodation. Improvements need to be made to the home`s policies and procedures to provide the base from which the care practice may continue to develop.

CARE HOME ADULTS 18-65 CARTREF RESIDENTIAL CARE HOME 1a Church Mount South Kirkby Pontefract WF9 3QT Lead Inspector John Gregory Unannounced 2 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cartref Residential Care Home Address 1a Church Mount South Kirkby Pontefract WF9 3QT 01977 643592 01977 643592 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr & Mrs Hall Mrs J Hall Care Home - Personal Care only 6 Category(ies) of Learning Disability - 6 registration, with number of places CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 18/11/04 Brief Description of the Service: Cartref is a residential care home providing personal care and accomodation for six younger adults who are subject to learning disabilities. The home has five permanent service users with one place for short stay care. The enterprise is privately owned and the owners live on the premises. The accomodation is an adapted detached house situated in a residential area of South Kirby, near Pontefract. All the residents accomodation is single and there is a large living room and a dining kitchen. The building is in the process of being extended and there is a car park to the front of the building and a sitting area and garden to the rear. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one afternoon in August 2005. The inspection was one hour in preparation and four and a half hours in fieldwork. The inspection focused on those areas the CSCI consider as critical to the care process. Policies procedures and records were examined relevant to the standards inspected. Two service users’ files were inspected that were subject to case tracking. Four staffing files were examined and one member of staff was interviewed. Two service users were interviewed in private and other service users were spoken to. Service users showed the inspector round on a brief tour of the facilities. The owners, Mr & Mrs Hall, facilitated the inspection. The inspector would like to thank the owners, staff and service users of Cartref for their time, cooperation and hospitality during this inspection. What the service does well: What has improved since the last inspection? The service provider has continued to develop the service users’ care planning process. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 6 The service provider has continued to develop plans to extend the premises to provide care for more service users. 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 RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 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 standard(s) 1,2 &5 The service provider must update the home’s registration category and enhance the information provided as part of the contract to correctly inform service users and their carers of the service user group and facilities provided by the home. Service users are admitted after a full assessment of needs undertaken by the home. EVIDENCE: It was noted that one service user has now reached retirement age and the service provider must apply to the CSCI for a variation in registration to reflect this change in order to keep persons informed of the service user group to whom services are offered. A requirement is made in this matter. The service provider’s contact is in the process of redevelopment and, when developed, should include all the areas determined by the National Minimum Standards in order to clarify the services provided for service users on an individual level. The files examined contained evidence of an assessment made by the home to ensure that the service users’ needs may be met. None of the service users CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 9 interviewed had been admitted in a time close enough to recollect the admission process. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6&9 The service provider should continue to develop the service users’ care plans into an holistic format to ensure that all their needs are met. A regular review of the plan should be undertaken to ensure it remains relevant to the service users’ needs. The service provider must develop a service user risk assessment process to ensure that their level of independence is maintained and enhanced. EVIDENCE: The service provider has worked to develop the care plans which now include areas on physical care and activities. The plans need to be continually developed to include all aspects of the service user’s life. There was evidence of service users’ care being reviewed under the care management arrangements. There was, however, no evidence of a review process within the home. The care plans of all service users should be reviewed at least once every 6 months to include significant persons in the service user’s life in order that the plan is kept relevant to the service users’ changing needs. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 11 There was no clear evidence on file of a formal risk assessment process of service users’ needs and activities, although discussion with the owners showed that the process was applied in an informal way. In order to more fully develop the service users’ independence, the process of risk assessment should be made formal and reviewed regularly. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 & 17 The service users live a stimulating lifestyle through attendance at day centres and a range of recreational and holiday breaks provided by the service providers. The service users were appreciative of the range and choice of food on offer. Some good work has been done in the home to address the dietary needs of one service user. EVIDENCE: All the service users confirmed their attendance at day centres for a varying number of days during the week where they undertake a wide range of activities including educational development and recreational activities. The service users spoke highly of their regular holidays in the caravans owned by the service providers and sited on the East coast of Lincolnshire. It was clear from discussion with service users, staff and the examination of records, that service users have contact outside the home with members of the CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 13 community involved in sporting activities and good contact with family in the area. The menu was examined and found to contain a good range of food. The record of food served was insufficient to make a judgement as to whether the menu was accurate. Service users were unanimous in their appreciation of the food on offer. It was clear from observation and records that one service user had been assisted to a commendable degree to improve her health and weight through dietary attention provided by the service providers and staff. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 &20 Service users receive a good level of physical and emotional care, through both day-to-day care and medical consultation. The medication procedures protect service users although some attention is needed to the detail of recording and policy development. EVIDENCE: The staff were seen to treat service users in a professional manner and the communication between both groups was seen to be good. Service users all dressed in their own style and had their rooms personalised. Anecdotal evidence was available for service users being assisted through grief reactions at the loss of family members. Service users with special physical needs had the necessary aids provided by the home. Evidence was seen on file of the service users being registered and regularly seen by the primary health care team. Service users were happy with the medical care they received. Other evidence was seen on file of the service users receiving specialist hospital services. The medication system was examined. It was found that, although the CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 15 medication procedure was basically sound, it did not contain all the areas recommended in the Royal Pharmaceutical Society guidance for care homes. A recommendation is made in this matter. A sample audit was made of the medication and it was found to balance. It was noted that the administering staff had not signed for the medication at the point of administration. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The service provider has a complaints procedure and the service users are confident to express their concerns to staff and have them resolved. The service users are protected from abuse but work needs to be done to enhance this protection by the development of a formal procedure for the prevention of abuse to vulnerable adults. EVIDENCE: The service provider has a complaints procedure that is understood by staff and in which the service users expressed confidence. There had been no complaints since the last inspection. Staff were clear of the action they would take in the event of abuse and the need to ‘blow the whistle’ on poor care. Some historical evidence was available of the service provider’s ability to be involved in protection issues. The service provider’s policy makes it clear that they have a good approach to the prevention of abuse. There is, however, no detailed procedure for staff to follow in making the policy a reality. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 17 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 standard(s) 24 & 30 The service users live in a comfortable and homely environment that is clean and tidy. EVIDENCE: The service users expressed their happiness with the home and its facilities. The accommodation was seen to be clean and tidy and furnished in a domestic manner. The outside of the home was in some disarray due to the impending development of the home but the service users did not express concern at this. The laundry was well equipped with domestic equipment. The walls and ceiling were of an impervious material and there were hand-washing facilities for staff. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 &35 The service users are supported by close staff teamwork in which the service providers pay a significant part. The service users are protected by a good recruitment policy. The staff are making significant movement toward qualification. Training needs to be improved in the area of the home’s specialism of learning disabilities in order that the quality of care continues to develop. EVIDENCE: The rota was examined and confirmed the verbal information that, with inclusion of the owners, there are two staff on duty during waking hours. The owners provide sleeping in cover. The staff files were examined and found to contain all the information necessary to protect service users. Staff are all close to completion of the NVQ level 2 which should, on completion, further enhance the quality of care on offer. All the staff have received recent training in the basics of physical care and health and safety issues. If the quality of care is to be further enhanced, all the staff should receive training in issues related to the home’s specialism of learning disabilities. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39&42 The service providers have the basics of a quality assurance system but this needs to be developed to provide a comprehensive quality assurance system. The service provider has a basically good system for fire safety. If the health and safety of all the staff and service users is to be protected as an integral part of the home’s life, then routine risk assessments need to be made of risks in the home including tests of the mains supplies and equipment. EVIDENCE: The service provider has a system for integrating the service users and other persons’ views into their thinking by use of questionnaires. This is not integrated into a correlated format or part of a planning cycle. The service provider undertake routine tests of the home’s fire alarm system and evacuation procedure and there has been a recent positive inspection by the Fire service. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 20 There was no evidence in the home of a work place risk assessment being undertaken, no information on COSSH, no mains tests or portable appliance tests. Although staff and service users felt safe living and working in the home, the health and safety processes must be formalised. CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 21 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 1 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 x 2 Standard No 31 32 33 34 35 36 Score x x 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 CARTREF RESIDENTIAL CARE HOME Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 1 x J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 22 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 YA 1 Regulation Care Standards Act 2000 13(4)b Requirement The service provider must apply for a variation of registration in respect of the service user over the age of 65 The service provider must ensure that any activity in which service users participoate are as so far as reasonabley practical free from avoidable risks The service provider must ensure that risks to the health or safety of service users are identified and as far as possible eliminated. Timescale for action 1/10/05 2. YA 9 1/10/05 3. YA 42 13(4)c 01/10/05 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. 3. Refer to Standard YA 5 YA 6 YA 17 Good Practice Recommendations The service users contract should contain all the information recommended in the national Minimum Standards. The service provider should continue to develop the care planning process for service users. The service provider should record all meals taken by service users on the record of food served. J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 23 CARTREF RESIDENTIAL CARE HOME 4. 5. 6. 7. 8. YA 20 YA 20 YA 23 YA 35 YA 39 The medication procedure should cover all areas recommended in the Royal Pharmaceutical Society guidance for care homes. The service provider should ensure that all medication is signed for by staff at the point of administration. The service provider should develop a procedure for the prevention of abuse to vulnerable adults. The service provider should ensure that all staff training in issues related to the homes specialism of learning disability The service provider should develop the quality assurance system and produce an annual planning cycle within which service users views are central CARTREF RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 24 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 RESIDENTIAL CARE HOME J51J01_S6238_Cartref_V233539_020805.doc Version 1.40 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!