Latest Inspection
This is the latest available inspection report for this service, carried out on 29th May 2008. CSCI found this care home to be providing an Good service.
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.
For extracts, read the latest CQC inspection for Carden Bank.
What the care home does well People who may be thinking of moving into this home will have enough information given to them to help them make the decision. Staff understand the aims and objectives of the home and put people at the centre of their care. They told us "people have a right to be treated as individuals and be respected". People can feel confident their needs will be assessed before they move in. The manager will visit them to do this before they are admitted. People have access to medical and healthcare professionals, as they need them. One visitor told us "My mum is here and the doctor is always called, we have peace of mind that she is being looked after no worries at all". There are good systems in place for the safe administration of medication.The home is developing its activity programme, people told us they are kept busy and active. They said "there`s a knack to throwing these darts, I really like it, keeps us active it`s a bit of exercise". Relatives told us "we always feel welcomed and completely satisfied with the home and the care it gives". The home has not received any complaints. It has a complaints policy that is displayed in the entrance hall and is also available in the Service User Guide. The manager told us "I have an open door policy any one can come and see me whenever they want, I will try to sort things out for them". The home is now under new ownership, the manager has a very clear vision for the future of the home and is taking steps to achieve this. People told us "since she has been here things are definitely getting better", Staff said "Kerry has arranged lots of training for us and is working hard to make it a lovely home". Staff have told us "we feel we give very good care and people come first all of the time". What has improved since the last inspection? This is the home`s first inspection. What the care home could do better: The home needs to consider more outdoor activities for people to take part in, such as day trips and other excursions. Staff should have training in the principles of the Mental Capacity Act 2005 so that they are aware of their roles and responsibilities in supporting people who may not have the capacity to make choices for themselves. The manager needs to make sure the home is complying with the Smoke Free legislation. The current arrangements for smoking in this home do not appear to be meeting the requirements of this legislation. Repairs to the roof need to be done to prevent further damage to the property occurring and to reduce the effects of damp in some of the resident`s bedrooms. The manager must make sure that when new staff are recruited the home is in receipt of two written references for each worker. This will reduce the possibility of unsuitable people from working with vulnerable adults. The manager should consider recording the minutes of resident and staff meetings. This will ensure that when people raise concerns, issues or points for action the home can demonstrate how it has taken steps to address them. CARE HOMES FOR OLDER PEOPLE
Carden Bank 16 Belvedere Road Horninglow Burton On Trent Staffordshire DE13 0RQ Lead Inspector
Mandy Beck Key Unannounced Inspection 10:00 29th May 2008 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Carden Bank Address 16 Belvedere Road Horninglow Burton On Trent Staffordshire DE13 0RQ 01283 563 841 01283 563 841 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) Kerry Ann Harrison vacant post Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of care: Care Home only Code PC To service users of the following gender Either Whose primary care needs on admission to the home are within the following categories: 2. Old age not falling within any other category (OP) 13 The maximum number of service users to be accommodated is 13. Date of last inspection This is the first inspection for this service. Brief Description of the Service: Carden Bank provides personal care for 13 older people. The home is situated close to Burton town centre and is accessible by local transport. Inside the home the environment is comfortable and relaxing. There are three communal lounges for people to use and also a smaller quiet lounge. People are encouraged to eat their meals in the dining room but can also eat meals in the lounge or the privacy of their own rooms if they choose to. Each person has his or her own bedroom; one bedroom has an en suite facility. There are no shared bedrooms. People are encouraged to personalise their rooms to make them feel more like home. There are bathing facilities although some do need to be modernised to meet people’s needs. The home is staffed by a friendly team who are committed to provide a good service to the people living in this home. People who live here are consulted about the service they receive and involved in the planning of their own care. The home charges £330 per week for residency. This fee does not include extra services such as hairdressing, chiropody, newspapers and magazines. People are asked to contact the service direct for further information. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • We also spent time talking to the people who use the service and to the staff who support them. • We looked at the care of two people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. What the service does well:
People who may be thinking of moving into this home will have enough information given to them to help them make the decision. Staff understand the aims and objectives of the home and put people at the centre of their care. They told us “people have a right to be treated as individuals and be respected”. People can feel confident their needs will be assessed before they move in. The manager will visit them to do this before they are admitted. People have access to medical and healthcare professionals, as they need them. One visitor told us “My mum is here and the doctor is always called, we have peace of mind that she is being looked after no worries at all”. There are good systems in place for the safe administration of medication. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 6 The home is developing its activity programme, people told us they are kept busy and active. They said “there’s a knack to throwing these darts, I really like it, keeps us active it’s a bit of exercise”. Relatives told us “we always feel welcomed and completely satisfied with the home and the care it gives”. The home has not received any complaints. It has a complaints policy that is displayed in the entrance hall and is also available in the Service User Guide. The manager told us “I have an open door policy any one can come and see me whenever they want, I will try to sort things out for them”. The home is now under new ownership, the manager has a very clear vision for the future of the home and is taking steps to achieve this. People told us “since she has been here things are definitely getting better”, Staff said “Kerry has arranged lots of training for us and is working hard to make it a lovely home”. Staff have told us “we feel we give very good care and people come first all of the time”. What has improved since the last inspection? What they could do better:
The home needs to consider more outdoor activities for people to take part in, such as day trips and other excursions. Staff should have training in the principles of the Mental Capacity Act 2005 so that they are aware of their roles and responsibilities in supporting people who may not have the capacity to make choices for themselves. The manager needs to make sure the home is complying with the Smoke Free legislation. The current arrangements for smoking in this home do not appear to be meeting the requirements of this legislation. Repairs to the roof need to be done to prevent further damage to the property occurring and to reduce the effects of damp in some of the resident’s bedrooms. The manager must make sure that when new staff are recruited the home is in receipt of two written references for each worker. This will reduce the possibility of unsuitable people from working with vulnerable adults. The manager should consider recording the minutes of resident and staff meetings. This will ensure that when people raise concerns, issues or points for action the home can demonstrate how it has taken steps to address them. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6 Quality in this outcome area is good. People will have enough information from this service to enable them to make a decision about living there. They can feel confident their needs will be assessed before they move in and that the home can meet those needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides good information about the service it delivers in the Statement of Purpose and the Service User Guide. Both documents give clear information about what to expect from the home when people agree to move in, the fees they will pay and how to make a complaint if they were to feel unhappy about anything. We looked at the assessments of two people as part of our case tracking process. It was pleasing to see that each person had a pre assessment and care plan, each plan evidenced that their needs, health and welfare needs had been discussed as part of the admission process. The manager also told us
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 10 that she will visit people at home prior to admission to give people the opportunity to discuss their needs and anxieties and to be sure the home can meet people’s needs upon their admission. People are also encouraged to spend time at the home before they agree to move in. This will give people the opportunity the “test drive” the service and speak to other people who live there before making their minds up about moving in. This home does not provide an intermediate care facility. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. People who use this service can feel confident the home will help them in meeting their needs. They will have access to medical and other healthcare services, as they need it. Medication systems in the home are safe and protect the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care plans and risk assessments for two people living in the home. Both people had been involved in the process of planning their own care and had signed the plan to demonstrate this. The home routinely assesses people’s risk in relation to moving and handling, falls and pressure sore development. This helps to reduce risks people because potential problems are identified at an early stage and addressed. We also noted the home keeps regular checks on people’s weight, in doing this they can be sure any adverse changes in weight are spotted and dealt with promptly. We noticed that one of the people’s plans we looked at there was
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 12 not weight recorded upon their admission. We have recommended the home should do this, as it will give them a baseline weight in order to measure any improvement/deterioration in future. We saw people have access to their own doctor should they need it. We also saw evidence to show that other health care professionals are included in people’s care. We spoke to relatives during this inspection that told us “my mum is here and the doctor is always called, we have peace of mind that she is being looked after no worries at all”. Medication practices in the home were generally safe. The staff we spoke to had good knowledge of the medication we observed them administering. They keep clear records of all receipts, administrations and returns. This means that people’s medication is not mismanaged and people have their medication as their doctor has prescribed it. We saw medication requiring cold storage is kept in the fridge in the kitchen, we have recommended the home puts this medication in a locked container inside the fridge to further reduce the risk to people living there. People told us they felt relaxed in the home. They also told us “the staff don’t rush you we are given plenty of time”. General observation throughout the inspection showed that staff have positive relationships with the people living there. Staff were able to demonstrate a good understanding of people’s needs and their individual preferences. We saw staff knocking on doors before entering people’s bedrooms and toilets. Those people who needed assistance at meal times were assisted to eat their meal in a sensitive and unhurried manner. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. People who use this service have the opportunity to take part in activites. Relatives and friends are encouraged to visit, as people would like them to. The home needs to develop a greater understanding of the Mental Capacity Act so that it can support people in making choices and taking control over their lives. People living in this home have choice about the meals they eat and can feel confident meals are nutritious and appealing to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home arranges activities for people living there. Activities range from musical evenings, target practice and reminiscence groups. One member of staff has also attended an activities training course. The manager told us “we are looking at improving all the time, if the residents want to do it we try to sort it out for them”. During this inspection we saw people taking part in sing alongs, others listened to music and people took part in softball darts. People are encouraged to take part if the choose to but are also encouraged to spend time on their own if they want to. They told us “there’s a knack to throwing these darts, I really like it, keeps us active it’s a bit of exercise”. At present there are no organised day trips or other activities planned out side of the
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 14 home. It is recommended the manager consider this to add to people’s enjoyment and social lives. Relatives said, “we always feel welcomed and completely satisfied with the home and the care it gives”. People are encouraged to be as independent as possible. The home does not handle money for people they are all encouraged to do this for themselves. To help with this there are locked facilities in each person’s room to keep valuables in. We looked around the home and in some people’s bedrooms. It was pleasing to see the home encourages people to bring their own personal items in with them when they move in. This helps to give an individual and personalised feel to each room. We discussed with the manager her understanding of the principles of the Mental Capacity Act 2005. She told us that this is an area for development. We have recommended the home seek some training in this area. They should do this so that staff are aware of their roles and responsibilities in supporting people who may not have the capacity to make choices for themselves. We spent time eating lunch with people. The meal was tasty and people said, “The food is good and if you don’t like it they try and do you something else”. The home does have a four-week menu but occasionally changes are made to it. Generally everyone was happy with the meal provision in the home. Some people told us the cook is experimenting with cake baking at present and they are trying them out. “The sponge with cream and jam is my favourite”. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. People who use this service can feel confident the home will listen to their concerns and act upon them. Staff do need further training in safeguarding adults but they are aware of their roles and responsibilities in protecting people from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy that is clearly displayed in the entrance hall and also in the service user guide. The home has received no complaints but does have a logbook in which to record them if the need arises. The manager told us that she generally records people’s grumbles directly into their own service user file. It was recommended that the manager for auditing purposes keep a separate record of grumbles. This would enable her to determine if there were any trends in people’s grumbles and for her to take action to address them. People living in the home told us “never had to make a complaint”, “no need to complain everything is ok”. We also spoke to relatives who told us “never worried, I know that Kerry would sort things out for us”. We also spoke to staff and asked them what they would do if someone made a complaint or was unhappy with the service. They said “listen to what they were saying, take notes and try to help to sort it out, I would also tell the manager straight away”. All of these responses give us confidence the home is able to deal with complaints on people’s behalf.
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 16 There are arrangements in place for the safeguarding of vulnerable adults. There could be improvements made which the manager has already begun to address. For instance not all of the staff have received training in Safeguarding Adults but this has been arranged. Once this has happened people living in the home will be further protected by staff that have the knowledge to support them should they make an allegation of abuse or misconduct. We spoke to the staff about safeguarding issues. They were able to discuss with us the different types of abuse and what they would do if they suspected or if an allegation of abuse was made to them. The home has policies in place to protect people such as Whistleblowing, this enables staff to raise their concerns in confidence should they choose to do so. The home does not use bed rails or other forms of restraint at this time. We looked at staff files and found the home is completing the required safety checks prior to new staff beginning work. Each member of staff is checked against the Protection of Vulnerable Adults list (PoVA) and a Criminal Records Bureau disclosure (CRB). The manager told us new staff do begin employment following a clear PoVAfirst check whilst this is acceptable this arrangement should not be considered the norm when recruiting staff. If staff must be employed this way the risks to people living in the home must be assessed and the new worker must be supervised until the CRB is returned. It is recommended that staff be in receipt of the CRB before they begin working in the home. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. People living here live in a well maintained, homely and comfortable home. The home is clean and hygienic and staff have received appropriate training in infection control. This will reduce risks to people who use this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home feels friendly and inviting. The new provider has told us of the improvements that have been made to the home in recent months. Outside the garden areas to the front and rear of the home have been tidied and make the home appear more inviting. The garden is also more accessible. New carpets have been laid in the entrance hall and walkways. Bedrooms have been decorated and there are plans for further redecoration and refurbishment in the future. We looked around the home and took time to see some people’s bedrooms. It was pleasing to see people are encouraged to
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 18 bring into the home their own personal possessions, this gives each room a personal feel and something that is special to each person. We noticed in two people’s bedrooms the ceiling plaster has “bubbled” the manager told us there was a problem with the roof and quotes for its repair had been obtained. This will need to be done and action must also be taken to reduce the smell of damp in those bedrooms affected by the leaking roof. We noticed whilst walking through the home that people are permitted to smoke in the small dining area next to the kitchenette. The current smoking arrangements within the home do not meet the Smoke Free Legislation and the manager should seek further advice about this and the changes that need to be made to environment in order to protect both the people and the staff who work there. There is some provision in the home for infection control. This could be improved with a supply of paper towels in toilets and bathrooms for hand washing. There is already a supply of liquid soap in toilets and bathrooms. The home does have laundry facilities on site and is able to launder clothing and linen at temperatures to reduce the spread of infection. Staff also reported that they have received training in infection control and also understood the importance of hand washing. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. People who use this service are supported by enough staff on duty to meet their needs. Staff are receiving training to enable them to support and understand people’s needs. There are some improvements needed to recruitment practices so that people can be assured unsuitable workers will be prevented from working with them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At present there are two staff on duty throughout the day and night. The manager is also available during daytime hours but is not counted in these numbers. People told us “we don’t have to wait long for one of them to come to us”, “the staff here are lovely”. The home has told us in their Annual Quality Assurance Assessment (AQAA) that care staff are continuing to work towards achieving their National Vocational Qualification (NVQ) level 2. At present over 80 of the current staff group have achieved this and the home is to be commended on this achievement. We looked at the recruitment process in the home; in order to do this we saw the staff files for three people. We found that most of the required information was held in each person’s file. We did note that one person had been allowed
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 20 to begin work in the home without the manager obtaining two written references. This was discussed during the inspection, the manager explained that this was not normal practice and generally there are two references for each employee. The manager was asked to obtain the references for the worker and to ensure that this does not happen again. This will help ensure people are being protected from being exposed to unsuitable workers. There was evidence to show the home is making sure people have required safety checks before beginning work such as the PoVA and CRB check as previously mentioned. New staff are supported through an induction when they begin working in the home. The manager showed us a smaller induction the home completes with workers that gives them an understanding of the home, such as fire exits, health and safety information and other practical information. The manager also showed us a more detailed induction workers complete over a longer period of time. It was recommended that the manager looks at the Skills for Care website and the common induction standards to make sure the homes induction is covering all of the required elements. Staff we spoke to said “I feel supported and have no problems asking for help”, “yes there was an induction, they showed me round and introduced me to people and the way they worked”, “yes, it was useful and told me about safety and a code of practice”. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. The manager has an understanding of the improvements needed within the home to develop the service. It is run in the best interests of the people who live there. People’s health and safety is promoted. The home does not manage people’s money but the home will support people in doing this for themselves. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered provider and manager for the home is Kerry Davies. She has been running the home in this role since January 2008. Mrs Davies has the necessary knowledge and qualifications to manage the home; she has obtained her Registered Managers Award and National Vocational Qualification level 4. Mrs Davies has very definite ideas about how the home is going to develop in
Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 22 the coming years. There has already been an improvement in the amount of staff training that has been undertaken. Staff reported to us “since Kerry has taken over the training has been really good, there’s lots of it”. The Annual Quality Assurance Assessment (AQAA) was completed on time and it gave us some of the information we needed but had limited information about the areas for improvement of the service. The manager told us “this is the first one I have filled in, I have done what I thought needed to go in”. The AQAA did tell us what the home has done well in the last 12 months “refurbishment and modernisation of environment, providing stimulating activities and updating staff training”. We saw evidence to show that this is happening. We also spoke to the manager about the Quality Assurance systems in place within the home. We saw evidence that audits have been taking place but the manager told us she wanted to improve the system. She told us that she regularly consults with people living in the home in meetings to discuss improvements, their ideas and wishes. What the home does not do is provide any written record, such as minutes of the meetings. This makes it difficult to see what issues and ideas have been raised as a result of these meetings and what action if any the home is taking to address them. It is recommended the manager begin to minute meetings so this can happen. The manager told us the home does not handle any money on behalf of the people living there. Each person manages their own money or is assisted by their family or advocate. The home provides a lockable facility in each person’s room for them to keep valuables safe. We looked at staff training in relation to health and safety. The AQAA told us the service had improved in this area. Staff also told us “since the new manager been here we have done lots of training”. We saw records of training that has been completed and more that is planned. Staff have had recent fire training and drills, first aid training, infection control and food hygiene. The home is well maintained and we checked some of the safety certificates such as five year electrical certificate, fire alarm and emergency call systems. The manager told us that a new fire alarm system had just been installed, this will add to people’s safety. Other safety systems were checked as part of the homes registration in January 2008 and were still up to date. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? New service 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 OP29 Regulation 19 (1) (c) Requirement The manager must make sure that two written references are available for each new worker. This will help prevent unsuitable people working with vulnerable adults. Timescale for action 30/06/08 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 4 Refer to Standard OP8 OP9 OP12 OP14 Good Practice Recommendations People should be weighed upon admission as part of the process. Medication that requires cold storage should be kept in a locked container inside the kitchen fridge. This will be an added safeguard for the storage of people’s medication. People should be given the opportunity to take part in activities outside of the home, such as day trips. Staff should receive some training in the principles of the Mental Capacity Act 2005 and to give them an understanding of their roles and responsibilities in supporting people under this Act. The manager should seek further advice from
DS0000070901.V362431.R01.S.doc Version 5.2 Page 25 5 OP19 Carden Bank 6 7 OP30 OP33 Environmental Health officer about smoke free legislation and the current arrangements in the home so that people are protected. The manager could further develop the home’s induction package by making sure it is meeting the common induction standards from Skills for Care The manager should begin to record the minutes of residents and staff meetings. This will enable her to see if issues raised as a result of these meetings have been actioned on resident’s behalf. Carden Bank DS0000070901.V362431.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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
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