Inspection on 28/09/05 for Castel Froma

This inspection was carried out on 28th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Castel Froma 13/02/09

Castel Froma 30/08/06

Castel Froma 24/03/06

Castel Froma 24/03/05

Castel Froma 11/10/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Castel Froma 93 Lillington Road Leamington Spa Warwickshire CV32 6LL Lead Inspector Justine Poulton Unannounced Inspection 28th September 2005 09:30 Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Castel Froma Address 93 Lillington Road Leamington Spa Warwickshire CV32 6LL 01926 427216 01926 885479 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) Castel Froma Charity Trustees Mrs Marilyn Kaliczak Care Home 57 Category(ies) of Physical disability (57), Physical disability over registration, with number 65 years of age (57) of places Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th March 2005 Brief Description of the Service: Castel Froma is a care home providing 24-hour nursing care for predominantly younger adults with a severe physical disability deriving from a head injury or neurological disease, such as Multiple Sclerosis. Seven rooms have en-suite toilets. There are extensive grounds. There are vehicles at the home to transport the residents. There is an “out- patient” service of hydrotherapy for National Health Service patients not resident at the home. Occupational Therapists, Physiotherapists and a Speech and Language Therapist are employed at the home. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday and was carried out from 9:30am until 17:30pm by two inspectors. The manager, residents and staff co-operated fully with the inspection. A total of 13 standards were inspected on this occasion of which 7 had shortfalls. Some requirements have also been carried forward from the previous report for this home, as they were either not met or not inspected on this occasion. A number of the residents were at home for all or part of the day. A number were spoken with informally. Staff members on duty were also spoken with informally. In addition to these records, files and policies and procedures were also inspected. The inspector would like to thank the manager, residents and staff for their cooperation and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Residents care plans would be more holistic and specific to their needs if information regarding activities and leisure pursuits were included. A review of generic risk assessments would benefit both residents and staff by ensuring that current accurate information is available. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 6 The homes medication procedures must be reviewed to address all areas of poor practice highlighted within the report to ensure residents safety. Maintenance issues detailed, including the repair of damaged tiles and paintwork in bathrooms must be addressed to improve the environment, and ensure thorough cleaning of these areas is possible. The health and safety of residents, staff and visitors must be maintained and improved by ensuring that the issues recorded are addressed. 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. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: No standards in this section were inspected on this occasion. Standard 2 will be inspected at the next inspection of this home later in the 2005/06 inspection year. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 There is a clear, consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet resident’s needs. Residents are being supported well when making choices and decisions through effective use of additional documentation. Residents risk assessments are compiled to safely ensure that staff have current information to meet the residents care needs. EVIDENCE: Residents have care plans in place, which detail their care and support needs from a medical model perspective. Four plans were looked at during this inspection. Information contained within them was clear and concise, detailing aspects of care and support such as night time care required, communication, bladder care, eating and drinking and pressure area care amongst others. As well as these care plans residents have completed psycho-social profiles with help from staff, which provide more person centred information. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 10 These profiles are written in the first person and detail how the residents wish to be supported by staff in areas such as making choices and decisions, relieving anxiety, increasing a sense of achievement and feeling good about myself. Personal dislikes are recorded, as are personal preferences such as getting up and going to bed times and how they wish to be addressed. Information concerning day time activities and how residents like to spend their social and leisure time was not fully available in any of the plans looked at. The manager said that this information is held by the occupational therapists as they support the residents in this area of their lives. Completed risk assessments were available within the files looked at, covering areas such as manual handling, the use of bed sides (complete with a signed consent form) and the use of an electric profiling bed. A Waterlow scale for pressure area care was available within all of the files. Evidence was available to confirm that care plans and risk assessments are reviewed on a regular basis, and updated as necessary. A wide range of generic risk assessments were available for the home, of which a small sample was looked at. The fire risk assessment, which was due for review in April 2004. No evidence was available to confirm that this was undertaken. Three differing risk assessments for staff and residents travelling in vehicles were available, therefore these need sorting to ensure that the most current is the one in use. Finally, a risk assessment for safe surface temperatures of radiators and pipes was looked at. This was written in 1997, and last reviewed in April 2003. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 17 Information concerning opportunities for residents to participate in appropriate activities and leisure pursuits was limited. A varied selection of food is available that meets residents dietary needs. EVIDENCE: A number of residents spoken with during the inspection said that they enjoyed life within the home. A large number of residents have activity programmes organised by the occupational therapy department within the home. These were not looked at on this occasion. An occupational therapy report was available within the files looked at, however more detailed information regarding actual day to day activities was not. During the inspection a quiz about Italy was organised by the Occupational therapy staff in the main lounge. A number of residents participated in this, and appeared to enjoy it. Those spoken with said that they found it fun. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 12 Staff were observed to support those residents that were not able to communicate verbally to join in and take part. During the inspection it was observed that the residents were offered a choice of what they would like to eat the next day. Each meal had two choices for each course, for example the main course for tea on the day of the inspection was macaroni cheese or a salad. Residents spoken with prior to lunch and over lunch said that the food was very good. They also said that if they did not want either of the choices available they could request something else. The cook said that the menus are currently planned by a designated staff member, in consultation with a dietician. Preliminary work has started with residents in a ‘ Dietician’s Support Group’ which will eventually look at improving menus and measuring the standard of the food provided. Lunch time was observed to be a very relaxed time for the residents. Individual support was provided by staff discreetly where required, with appropriate aids and adaptations being used to ensure that residents were able to eat and enjoy their meals. The kitchen area had recently been cleaned. Food was stored appropriately and fridge and freezer temperatures were recorded daily. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 The personal care and support needs of the residents are assessed and recognised with evidence of specialist services being readily available to them. The system for medicine management is not robust enough to ensure that all medication is administered to residents safely, and stored appropriately. EVIDENCE: Evidence was available within the care plans and to some degree the psychosocial profiles looked at that confirmed that residents receive personal support as they wish. Specific information concerning hygiene, bowel and bladder care, moving and handling and controlling body temperature is detailed, with evidence to confirm that regular reviews are undertaken as necessary. One resident was observed to have an inappropriate physical intervention in place to prevent him from scratching himself. No protocol for this was available within the care plan documentation for this gentleman. The home is divided into three areas, each of which has its own medication trolley. A number of areas of concern were identified regarding the stock, storage and administration of medication, which were discussed with the manager during the inspection. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 14 Evidence of misadministration and lost tablets not being recorded was identified, medication leaving the building with the resident when out for the day was not documented on the medication administration chart, medication that was not prescribed or part of the homes agreed homely remedies policy was recorded as having been administered, PRN medication was recorded as having been administered without agreed documented protocols, or agreement from a GP and medication trolleys were observed to be left open and unattended during the administration of medication. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: These standards were not inspected on this occasion. Standards 22 and 23 will be inspected at the next inspection of this home later in the 2005/06 inspection year. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 28 The home is large, with a considerable number of residents living together in a group. Outstanding maintenance issues, once addressed will ensure that residents comfort and safety is improved and maintained EVIDENCE: Castel Froma is a care home providing 24-hour nursing care for predominantly younger adults with a severe physical disability deriving from a head injury or neurological disease, such as Multiple Sclerosis. The home is large, and consists of the original building and a more recently added extension. It is divided into three areas. Seven rooms have en-suite toilets. The main lounge and dining area have recently been redecorated. Bedrooms looked at were all personalised. A number of maintenance and storage issues require addressing as discussed with the manager during the inspection. These consist of damaged tiles in bathrooms and chipped paintwork on bathroom doors, dirty pull cords on lights and call systems, stained bed bumpers and appropriate storage when not in use and appropriate storage for pads and related products. The home has considerable shared space available for use by the residents, consisting of a large lounge and dining area, and two smaller lounges, all of which are decorated nicely and well furnished. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 36 The recruitment policy and procedure for this home ensures that service users are supported and protected from harm by the people caring for them. The staff working in this home have a very good understanding of the residents support needs, this was evident from the positive relationships observed between the staff and residents. The reduced amount of staff supervision leaves residents and staff vulnerable to potential risk. EVIDENCE: The home has a large diverse staff team consisting of qualified nurses, care assistants, support assistants, lounge assistants, companions, cooks and kitchen staff, domestic staff, physiotherapists, physiotherapy assistants, occupational therapists and occupational therapy assistants as well as a large group of volunteers. Alongside this are the administration and personnel staff. Information looked at in staff recruitment files confirmed that the home undertakes safe recruitment practices that protects the residents. All necessary documentation such as criminal records bureau checks, Pova First checks (where necessary), two written references, an application form and terms and conditions of employment were available within the files sampled. Out of the six files looked at only three had evidence of identification. Staff supervision is carried out on a group basis by the senior nurse and senior physiotherapist. Individual supervision is provided by the manager as and when necessary in addition to this. Records available did not confirm that the home is meeting the national minimum standard of 6 supervisions per year as yet, however progress has been made since the last inspection. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health and safety of residents, staff and visitors is maintained as far as practicable. Completion of the maintenance issues highlighted will provide further safeguards to the health and safety of people living and working within the home. EVIDENCE: The health and safety of residents, staff and visitors within the home is generally maintained, however there were a number of areas where improvement is required. A legionella risk assessment was carried out in July of this year. Fire alarms are tested on a weekly basis, with records available to confirm this. Emergency lighting is tested at least monthly, and a record of any action taken was available. Six monthly bed maintenance checks are undertaken with any repairs being carried out as necessary. Drivers licences are checked on an annual basis. Clinical waste is collected under contract. Periodic servicing of passenger lifts was available as was evidence to confirm that most hoists are serviced regularly. Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 19 An annual gas safety check was available for October 2004. Records to confirm that portable electrical appliance testing is carried out on an annual basis was not available. Plug stickers on appliances sampled evidenced that testing in this area is overdue, as it was last carried out in January, March and May 2004. A number of hot water pipes in shower and bath areas were very hot to the touch, as were a number of radiators in high risk areas. As recorded earlier in this report the risk assessment for this was last updated in 2003. During inspection of the building it was noted that boxes and other items were being stored in some bathrooms and toilets, making them difficult to access for residents. It was noted that some residents had hazardous substances and alcohol items in their bedrooms, which were not stored safely. The water temperature of those showers tested was above 43oC, and thus likely to cause injury to residents Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x x LIFESTYLES Standard No Score 11 x 12 2 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Castel Froma Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000059286.V259305.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 YA12 Regulation 16(2)(n) Requirement Information regarding resident’s activities and leisure pursuits must be included within their care plans. A review of all generic risk assessments must be undertaken. The home must only administer medication to residents, which has been prescribed to them or is part of the agreed homely remedies policy. PRN medication must only be administered according to agreed documented protocols or on instruction by a GP. The home must maintain a record of PRN or none blister pack medication stock levels. All incidents of misadministration, lost tablets and other medication errors must be clearly recorded. Medication taken out of the home by residents must be clearly documented on the Timescale for action 31/01/06 2 3 YA9 YA20 13(4)(a) 13(2) 31/12/05 30/11/05 4 YA20 13(2) 30/11/05 5 YA20 13(2) 30/11/05 6 YA20 13(2) 30/11/05 7 YA20 13(2) 30/11/05 Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 22 8 9 YA20 YA24 13(2) 23(2)(b) 10 11 12 YA24 YA24 YA36 23(2)(c ) 23(2)(c ) 18(2) 13 YA42 13(4) 14 15 16 17 18 YA42 YA42 YA42 YA42 YA42 13(4) 13(4) 13(4) 13(4) 13(4) medication administration record chart. Medication trolleys must be locked when not attended by qualified staff. All damaged tiles and chipped paintwork in bathrooms and on bathroom doors must be repaired. All pull cords on lights and call systems must be cleaned. Stained bed bumpers must be cleaned and stored appropriately. Staff must be provided with formal recorded supervision at least 6 times per year. (Part met) Portable appliance testing must be carried out on an annual basis. Evidence to confirm that this has been carried out must be available. Hot water pipes and radiators in high risk areas must be covered. Generic risk assessments must be reviewed and updated where necessary. Incontinence Pads and related products must be stored appropriately. All hazardous and substances must be stored safely in locked cupboards. All showers must be set at a safe temperature. 30/01/05 31/01/06 31/12/05 30/11/05 31/01/06 31/01/06 31/12/05 31/01/06 31/12/05 31/12/05 31/12/05 Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Castel Froma DS0000059286.V259305.R01.S.doc Version 5.0 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. 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