Care Home: Carlton Villas

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What the care home does well It is a small and friendly home that caters mainly for people from the local area. It is comfortable, clean, and homely. People told us they have confidence in the manager. They said they can talk to her and any concerns they have are dealt with immediately, one person described the manager as “wonderful”. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Visitors are welcome at any time and people can see their visitors in private. One person’s relatives said they would give the home 9 out of 10, (10 being the best). We asked people what they home does well, one person who lives there said, “look after me, I am happy”. One health care professional said the staff seem caring and compassionate and call appropriately for medical intervention for people. During our visit we saw that staff were kind and respectful and spent time talking to people and encouraging them to take part in whatever was going on. People are encouraged to bring some of their personal belongings with them and people had photographs, ornaments, or items of furniture in their rooms. This helps to make it feel more homely. The home does all the required checks before new staff start work and this helps to protect people. Staff are supported and are provided with training opportunities, this helps to make sure they have the knowledge and skills they need to meet people’s needs. What has improved since the last inspection? The manager was appointed just after the last inspection in 2007. Before her appointment the home had been through an unsettled period and she has provided the stability and leadership needed to deliver good quality outcomes to people using the service. There were four requirements following the last inspection. Three of these have been met and the remaining one has been carried forward as a recommendation. The way people’s social care needs are dealt with has improved and there is now a more individualised approach to supporting people to follow their personal interests and make the most of their abilities. The manager is continuing to develop this aspect of the service. What the care home could do better: The bathing facilities should be improved so that people can have a choice of suitable bathrooms close to their bedrooms. The night staffing arrangements should be kept under review to take account of people’s changing needs to make sure people continue to be properly cared for and safe at night. In their annual quality assurance assessment (AQAA) the home showed us that they have identified areas where they want to continue to improve the service. For example, organising more outings for people, continuing to improve theCarlton VillasDS0000001303.V377689.R01.S.doc Version 5.2 care records so that they can give people more personalised care and continuing to encourage people to decorate and furnish their rooms in accordance with their personal tastes. Key inspection report CARE HOMES FOR OLDER PEOPLE Carlton Villas 2 Pelham Road Undercliffe Bradford West Yorkshire BD2 3DB Lead Inspector Mary Bentley Key Unannounced Inspection 15th September 2009 10:00 DS0000001303.V377689.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlton Villas Address 2 Pelham Road Undercliffe Bradford West Yorkshire BD2 3DB 01274 634913 0113 2509633 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 John Thomas Lamb Mrs Helen Margaret Lamb Manager post vacant Care Home 13 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9), of places Physical disability over 65 years of age (2) Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2007 Brief Description of the Service: Carlton Villas is a detached converted property. The home provides personal care for up to 13 people. The home does not provide nursing care. If people living in the home need nursing care it is provided by the district nurses. The accommodation consists of nine single and two double bedrooms, two of which have en-suite facilities. The communal rooms are on the ground floor; there is a lounge, a conservatory, and a dining room. There is good access to the home for people with disabilities, however the home does not have a passenger lift, there is a stair lift to the first floor. The home has a small but pleasant garden that people can use, weather permitting. There are a small number of car parking spaces in the grounds and parking is allowed on the roadside. The home is close to a good range of local amenities including shops, public houses, a library, and a park. It is well served by local transport. A specialist home for people with learning disabilities has been built in the grounds. This is separate unit which is run independently of the care home. In September 2009 the weekly fees ranged from £375.00 to £395.00. Additional services such as hairdressing, private chiropody, newspapers, and transport can be arranged for an extra cost. Please contact the home for more detailed information about the fees. Copies of inspection reports are available from the home on request. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience Good quality outcomes. This is what we used to write this report • 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. The results of any visits that we have made to the service in the last 12 months and information from the Annual Service review in 2008. Information we have received from people using the service or their representatives. We received six surveys in total; these were from people living in the home, visiting health care professionals and staff. 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. Relevant information from other organisations. A site visit carried out by one inspector in one day. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records including care records, looked at some parts of the home and observed staff as they carried out their duties. • • • • • • We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: It is a small and friendly home that caters mainly for people from the local area. It is comfortable, clean, and homely. People told us they have confidence in the manager. They said they can talk to her and any concerns they have are dealt with immediately, one person described the manager as “wonderful”. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Page 6 Visitors are welcome at any time and people can see their visitors in private. One person’s relatives said they would give the home 9 out of 10, (10 being the best). We asked people what they home does well, one person who lives there said, “look after me, I am happy”. One health care professional said the staff seem caring and compassionate and call appropriately for medical intervention for people. During our visit we saw that staff were kind and respectful and spent time talking to people and encouraging them to take part in whatever was going on. People are encouraged to bring some of their personal belongings with them and people had photographs, ornaments, or items of furniture in their rooms. This helps to make it feel more homely. The home does all the required checks before new staff start work and this helps to protect people. Staff are supported and are provided with training opportunities, this helps to make sure they have the knowledge and skills they need to meet people’s needs. What has improved since the last inspection? What they could do better: The bathing facilities should be improved so that people can have a choice of suitable bathrooms close to their bedrooms. The night staffing arrangements should be kept under review to take account of people’s changing needs to make sure people continue to be properly cared for and safe at night. In their annual quality assurance assessment (AQAA) the home showed us that they have identified areas where they want to continue to improve the service. For example, organising more outings for people, continuing to improve the Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.2 Page 7 care records so that they can give people more personalised care and continuing to encourage people to decorate and furnish their rooms in accordance with their personal tastes. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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 Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Standard 6 does not apply to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is information available to help people decide if the home is suitable for them or their relatives. People’s needs are assessed before they move in. EVIDENCE: People told us they had been involved in choosing the home. They said they had been given enough information to help them decide if the home was the right one for them or their relatives. A copy of the Statement of Purpose and a Welcome pack are available in the reception area and they provide clear information about the service. The manager explained that people’s needs are always assessed before they move in to make sure the home will be able to meet their needs. As part of Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 10 this assessment the manager usually visits people, either at home or in their temporary place of residence, to find out about their needs. People are encouraged to visit the home before making a decision about moving in, this usually involves people coming for a meal and spending a few hours in the home so that they can meet other people living in the home and staff. The manager said people often visit on more than one occasion before making a decision about moving in. There was no record of these pre-admission assessments in two of the care records we looked at. The manager explained the circumstances of these admissions, in one case the person had come in as an emergency for a trial period and information about his needs was provided by Social Services before he moved in. In the other case the person had visited before initially coming in for a short period of respite care. Following the period of respite care he decided to remain in the home. Information about people’s needs which is obtained during the pre-admission assessment should be recorded and available for staff so that they have information about people’s needs when they move in. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and health care needs are met in a way that takes account of their wishes and abilities and their privacy and dignity is respected. EVIDENCE: People told us they get the care and support they need. Everyone living in the home has a care plan setting out how their personal, health and social care needs will be met. We looked at two people’s care records. Information about people’s needs is well set out and easy to find. When people are identified as needing help with a particular area of daily living, for example to get washed and dressed, there is a care plan to show how this help will be provided. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 12 There are risk assessments in place for areas of potential risk, for example falls, nutrition and pressure sores. In one person’s records we saw that they had been identified as being at risk of developing pressure sores. The home had contacted the district nurses who had provided a pressure relief mattress and cushion and this was recorded. However, the home did not have a care plan showing what action they are taking, for example making sure that the mattress and cushion are being used at the correct settings and helping the person to move. This was discussed with the manager who said she would deal with it. We saw that people’s weights are recorded every month and there were no concerns about people’s nutritional status. The care records include an assessment of people’s capacity to make decisions about their day to day lives. We saw evidence that people or those close to them are involved in planning and reviewing how their care needs are met. The daily notes made by staff are detailed and give a good picture of how people are and how they are spending their time. The records showed that people have access to a range of NHS services such as GPs, district nurses and podiatry services. We looked at the way people’s medicines are managed. Only staff that have been trained are allowed to help people with their medicines and training is provided by the supplying pharmacist. The manager told us the home has recently changed to a new pharmacy and are getting a much better service. This helps them to make sure that people get their medicines as prescribed. The medication administration records were up to date and correct. The home has secure storage for controlled drugs. We checked the controlled drugs and the stock balance was correct, however there was an error in the records. On further investigation we saw that this was because a new supply of medicines had been recorded on the wrong page. This was discussed with the manager. Throughout the day we saw that staff were kind and respectful. There was a lot of interaction with people and some good humoured banter which created a relaxed and warm atmosphere. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given the support they need to follow their personal interests and make the most of their abilities. People are offered a variety of nutritious food and are involved in menu planning. EVIDENCE: People told us there are usually activities for them to take part. One person said they would like more activities for those who are able to take part. People’s care records have information about their social needs and interests. This includes information on daily activities, for example their preferred daily routines, weekly activities and information on how they like to mark special occasions. There is also information about people’s religious needs, whether they follow any particular faith and what, if any, support they need to do this. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 14 The company employs an activities organiser and she visits the home twice a week. At other times staff organise activities for people. The manager said they do not have a set programme for activities, they prefer to respond to how people are feeling and what they want to do. Activities include games, music, singing and manicures. Special occasions such as birthdays are celebrated, usually with a party. There was a lively atmosphere in the home during the morning, there was music and people were singing. Visitors said it is usually fairly lively and can at times almost seem too noisy. In the afternoon people had some quiet time after lunch listening to a recording of Max Miller. People are able to choose whether or not they join in the planned activities. One person told us they prefer to stay in their room, reading the paper and listening to music. We saw that staff spent time talking to people or engaging them in activities. Staff know people well and are able to talk to them about their individual interests. People were alert and interested in their environment. Two ladies in the lounge were enjoying watching and commenting on people coming and going to the home next door. Another person likes to have a regular walk around the grounds and also goes to the local shops. Visitors told us they are always welcome and people who are able go out with family or friends. People told us the food is good. People are involved in planning the menus and every effort is made to cater for people’s personal preferences. The home has a four weekly menu and most of the food is home cooked. The meal service at lunchtime was well organised, the food was nicely presented and people were given time to enjoy their meals. Staff were available and where necessary prompted or helped discreetly so that people would not feel embarrassed. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure complaints are taken seriously and acted on and to protect people. EVIDENCE: People who completed surveys for us said they know who to talk to if they are unhappy about any aspect of the service. Relatives told us they have no hesitation in talking to the manager if they have any concerns and said their concerns are taken seriously and acted on. Information about the complaints procedure is displayed in the home. The contact details for the Care Quality Commission need to be updated on this notice, the manager said she would deal with this. The manager told us the home has not had any formal complaints in the last 12 months. She said she encourages people to talk to her if they have any concerns so that issues can be resolved as they arise. We received some concerns about the service last year. We passed these concerns to the home and they were investigated and dealt with. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 16 There are procedures in place to make sure people are protected. The manager is aware of the local authority safeguarding procedures and has used them appropriately when necessary. The majority of staff have attended training on safeguarding (the protection of vulnerable adults) and the remainder are booked on this training. This helps to make sure people are protected by increasing staff awareness of safeguarding issues. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Carlton Villa provides a homely and comfortable environment for people. However, some improvements are needed to make sure it is suitably equipped to meet people’s needs. EVIDENCE: The home was clean when we visited and people told us it is always clean and fresh. The communal rooms are on the ground floor and improvements have been made to the conservatory which has made it a nicer room for people to use. When we visited there was a pool table in the conservatory and one person was playing a game with staff. The manager told us the table is folded up Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 18 when it is not being used. There were books, games and other items used for activities in the conservatory. The dining room is small but adequate to meet people’s needs. The medicine trolley and some paperwork are kept in the dining room because there is not much storage space in the home. The manager said she would ideally like to have round dining tables but the room is not big enough to accommodate this. There are some bedrooms on the ground floor but the majority are on the first floor. The home does not have a passenger lift; therefore people have to be able to walk up the stairs or use the stair lift. The home has one hoist to help people to move and this is kept on the ground floor. This means that if people on the first floor need assistance, for example, if they fall, there is no equipment available for staff to help them move. One health care professional who visits described the environment as “awkward” and said this can make it difficult at times to manage people’s care, for example when they have an acute illness. People’s bedrooms are suitably furnished and people have personal belongings such as ornaments and photographs in their rooms. The home has 2 shared rooms however the manager said people are given the option of having them as single rooms if they prefer. Some of the bedroom carpets are showing signs of wear and tear and need to be replaced. The manager has already identified this as an area for action. The home has three communal bathrooms but only one is an assisted bath. When we visited in 2007 we identified concerns about the bathroom on the first floor. The bath is not suitable for use by people who need assistance and this means that most of the people who live on the first floor have to go downstairs to use the assisted bath. Nothing has been done to improve the bathing facilities and this was discussed during the visit. Improvements have been made to the laundry since we last visited; it is suitably equipped to meet people’s needs and provides an improved working environment. There are suitable systems in place to reduce the risk of cross infection. The home has been awarded a 3 star rating (the best is 5) by environmental health for its standards of food hygiene and safety. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are usually enough suitably trained and competent staff to meet people’s needs. People are protected because all the required checks are done before new staff start work. EVIDENCE: People told us staff are usually available when they need them and said staff listen to them and take notice of what they say. One person said “there is always someone there and some are very caring”. There are usually 3 care staff on duty in the morning and 2 in the afternoon and evening. Overnight there is one carer in the home and the manager is on call. Since the last inspection there have been some concerns about the staffing of the home at night. These concerns were raised with the home at the time and they reviewed the night staffing arrangements and the procedures for staff to follow if they need assistance. This was discussed with the manager. She told us she is confident that the night staffing arrangements are sufficient to meet Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 20 the needs of the people living in the home. She said she takes the night staffing arrangements into account when assessing the needs of people who are considering moving into the home. She said she is satisfied that the current arrangements are working and people are properly cared for and are safe at night. The home employs separate staff for housekeeping and catering. They have made changes to the housekeeping rota and now have housekeeping staff at the weekend. This means that care staff have more time to spend with people. Staff told us they received induction training when they started work, they said this was good and gave them the information they needed to meet people’s needs. They also said they get the training they need to care for people properly. One new member of staff said other staff were helpful when she started working at the home, she said she enjoys working there. The records showed that the induction training provided to staff meets the Skills for Care standards. These are nationally agreed standards designed to give new staff the knowledge and skills they need to care for people properly. The company employs a training manager and she was in the home on the day we visited talking to staff about planned training. Records are kept of all staff training. The records showed that in addition to mandatory training, for example moving and handling and fire safety, staff receive training on subjects such as dementia care, nutrition and medication. There is an expectation that staff will enrol for NVQ (National Vocational Qualification) training when they have completed their induction training. Seven care staff have obtained an NVQ at level 2 or above and 3 more are working towards this. Staff told us that they were not allowed to start work in the home until they had received their CRB (Criminal Records Bureau) disclosures and the records confirmed this. The records also showed that two written references are obtained before new staff start work. The manager told us she does not allow staff to start work when they have received a PoVA (Protection of Vulnerable Adults) First check because the staff team is too small to carry out the required supervision. The manager told us the company policy is not to retain CRB disclosures although details of the disclosures are recorded. The Care Quality Commission’s guidance on CRB disclosures makes it clear that regulated services are required to keep these disclosures for inspection. We have written to the provider about this. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is appropriately managed and provides a safe place for people to live and work. People are given the opportunity to share their views and contribute to the day to day running and improvement of the service. EVIDENCE: The registered manager has been in post for approximately two years. People told us the manager is approachable and said they have confidence in her. Staff told us the manager gives them the support they need to care for people. The home manager is supported by a senior manager from the company who Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 22 visits the home at least once a month. During this visit the senior manager checks various aspects of the service and reports from these visits are kept in the home. The home has meetings for people using the service and their relatives twice a year. They have also started to have meetings just for people living in the home. The first meeting was held in August and people talked about activities and the menus. The home sent quality assurance questionnaires to people in July this year. Only two had been returned when we visited. They showed people are satisfied and indicated that the manager has made improvements to the service. When all the responses are received the results will be analysed and feedback will be given to people using the service. The manager completed the annual quality assurance assessment (AQAA) and it gave us the information we asked for. The manager has done training on the Mental Capacity Act and the Deprivation of Liberty. Training is being organised for staff. Two of the senior managers in the company are designated to take the lead on issues relating to the Mental Capacity Act and Deprivation of Liberty. This helps to make sure that people’s rights are protected and promoted. No one was being deprived of their liberty at the time we visited. The home holds some personal money for people. This is held securely, all transactions are recorded and receipts are obtained for any money spent on people’s behalf. The system is checked by the company’s head office to make sure people’s money is being managed properly. One person told us they are happy for the home to look after their money, they said they get their money whenever they want and are able to go to the local shops. There are suitable systems in place to make sure equipment and installations are maintained and serviced at the required intervals. The manager audits accidents to identify any actions that are needed to reduce the risk of similar incidents happening again. The home is in the process of introducing a room risk assessment. This will be used to identify potential hazards in people’s bedrooms, for example the way furniture is arranged, so that action can be taken to reduce the risk. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 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 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x 2 x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Information obtained about people’s needs during the preadmission assessment should be recorded and available for staff so that they have information about people’s needs at the time of admission. The bathroom on the first floor should be upgraded to an assisted bath or disabled access shower so that people have a useable bathroom close to their bedrooms and so that people have a choice of bathing facilities. The night staffing arrangements should be kept under review to take account of people’s changing needs and the home’s fire risk assessment. To make sure that people continue to be properly cared for and are safe at night. 2. OP21 3. OP27 Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 26 Carlton Villas DS0000001303.V377689.R01.S.doc Version 5.3 Page 27 - 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!