Inspection on 11/08/05 for Castelayn

This inspection was carried out on 11th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Castelayn 23/01/07

Castelayn 14/03/06

Castelayn 17/11/04

Castelayn 04/05/04

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

CARE HOMES FOR OLDER PEOPLE Castelayn 2 Leighton Drive Sheffield South Yorkshire S14 1ST Lead Inspector Shirley Samuels Unannounced 11 August 2005 12:00-18:00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Castelayn Address 2 Leighton Drive Sheffield South Yorkshire S14 1ST 0114 2398429 0114 2398216 None Sheffcare Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Valerie Wait PC Care Home Only 40 Category(ies) of PD(E) Physical disability - over 65 (4) registration, with number OP Old Age (36) of places PD Physical disability (4) Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 4 PD beds can also be for people who are PD(E) and are situated in a separate wing. Date of last inspection 17th November 2004 Brief Description of the Service: Castelayn is a purpose built 40 bed home. The home offers personal care for 36 older people and personal care for 4 people with physical disabilities. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, pubs, etc). It is over three floors all serviced by a lift. All the bedrooms are single and there are a suitable number of lounges and dining rooms. The gardens are landscaped and it has a small car park. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over six hours. Ten service users, three members of staff, a professional visitor and the senior team leader who was in charge were spoken to. A selection of records was examined and an inspection of the building was made. What the service does well: What has improved since the last inspection? What they could do better: The medication procedures need to be monitored to make sure that all medication received into the home is properly recorded and that medication no longer in use is returned to the pharmacist. Cleaning materials and other hazardous substances were insecurely stored, posing a risk to service users. In the grounds of the home four old fridges with doors still attached were discarded. They were in an area were small children could gain access and become trapped. These were made safe and arrangements made for there collection. In one area of the home service users records were insecurely stored. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 6 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. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 Service users are provided with the information they need to make an informed choice about where to live. EVIDENCE: Service users said they were given information about the home before they moved in. They were able to visit and familiarise themselves with the staff service users and the building. Each service user was provided with a service user guide, which informed them about the home and the activities available. There was information in the service user guide, which informed service users that they could have access to information kept about them but that a charge of £10 may be required in certain cases. The circumstances under which a charge maybe made was not explained. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 &10 Service users were able to be responsible for their own medication, in the main they were protected by the procedures in place for the management of medication. Service users were treated with respect and their right to privacy was upheld. EVIDENCE: Medication procedures were in place and staff received training and their competence to safely administer medication was monitored. Service users said they were able to administer their own medication and secure facilities were provided in their bedrooms for storage. There were two examples of medication stored in the medication cupboard, which were not recorded on the medication administration sheet. The designated person said these medications were administered when required and had not been used for some time. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 10 Service users said staff respected their privacy “they always knock on the door before coming into my room”, “I am given a choice about food and the how to spend my time”, “staff look after me well”, “I am able to soak in the bath and they offer me the assistance needed”. Staff said they respected the privacy and dignity of service users by knocking on doors, closing doors behind them, and giving choice of clothing and involving service users in care planning. This was to make sure that service users views and wishes were recorded and implemented by staff. Service users said the staff spoke to them in a proper manner and were respectful, kind and caring, this promoted a feeling of wellbeing. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 &15 Service users were able to maintain contact with family/ friends and were helped to exercise control over their lives. Service users received a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: Service users said their family and friends were able to visit and were made welcome. They were able to spend their day as they wished and gave examples of being given choices about what time to get up go to bed, meals and activities. They said they were able to go out of the home for walks some with assistance some without. Some service users used local transport to travel around the city independently. This promoted independence and allowed service users to have control over their lives. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 12 Service use said they were satisfied with the food and added that much improvement had been made since the last inspection. They stated quite strongly that they preferred “good old fashioned food, nothing fancy”. Service users said “there was always a choice at every meal”, “plenty of variety” and that snacks were provided in-between meals. Service users said the cook did consult with them about the food and they felt able to raise any issues and give feedback. This ensured that service users preferences and wishes were taken into consideration, acted upon and that they were able to influence service provision. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Service users were protected from abuse. EVIDENCE: There were policies and procedures in place to protect service users and for responding to any allegation of abuse. Staff said they had received training on adult protection and were able to give examples of abuse. Service users said they felt safe, “the staff are very kind they always speak to me in a proper manner”. This promoted the service users sense of security and wellbeing. One member of staff however, was not clear about the procedures to follow should an allegation of abuse be reported to them. They did not demonstrate knowledge of ongoing procedures following an allegation, eg protection of service users and who might be involved in any investigation. This could place service users at risk. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 & 26 In he main service uses lived in a safe comfortable well-maintained environment, which was clean pleasant and hygienic. EVIDENCE: Service users said they were satisfied with their bedrooms and the arrangements for keeping them clean and changing bedding. The communal areas were generally in a good state of repair, however, some areas of the home had damaged wallpaper, and “shabby” kitchen units in some of the kitchenette areas. Water damage was noted to ceilings in one bathroom and one service users bedroom. The staff said that changes had been made regarding the cleaning arrangements for the home. Some areas were cleaned by the homes domestic staff, with outside contractors being responsible for other areas. This was a new arrangement and was being monitored and kept under review. Records showed that service users and relatives were being consulted and were able to comment on their level of satisfaction with the new arrangements. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, & 30 In the main, the number and skill mix of the staff met service users needs and staff are trained and competent to do their job. EVIDENCE: Service users said that there was usually enough staff on duty, but added there were occasions where they seemed to be short staffed. Two weeks staff roters were checked, these showed that the agreed staffing levels were being maintained. Minutes of a residents meeting held in February 2005 detailed a discussion about staff shortages and the action to address this. Staff said that the dependency level of the service users on the top floor was increasing, and in their view the level of staffing in this area needed to be reviewed to ensure the needs of the service users were met. Service users said staff knew how to look after them and that they were in safe hands. Service user comments included, “they look after me well”, “they will do anything for you”, “they are smashing I cannot crumble”, “they work hard and put some hours in”. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 38 There are policies and procedures in place regarding the appropriate storage of service users information, this was not fully adhered to. In the main the health safety and welfare of the service users and staff were promoted and protected. EVIDENCE: In one area of the home, service users records were found insecurely stored in a bureau, which was not locked, increasing the risk of unauthorised access. Staff said they received health and safety, first aid, moving and handling and food hygiene training. They added that they were provided with all the equipment necessary to carry out their duties safely and to protect service users from harm. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 17 Hazardous substances including prescribed shampoos, surface cleaner and dishwasher tablets were found insecurely stored in several areas around the home. Creating an unnecessary hazard and risk to service users. This was brought to the immediate attention of the person in charge and made safe. Four old fridges were discarded in the bin area these posed a risk to children who could gain access to this area. The fridges were made safe at the time of the inspection, by removing the doors and arrangements made for them to be collected. A member of staff confirmed that the fridges were removed on Friday 12/8/05. Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x x x x x 2 2 Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 1 Regulation 5 Requirement The statement referring to the £10 charge in the service user guide must be changed to give a clear understanding of what the fee may be charged for.The £10 charge, and its purpose must be included in the service users contract/statement of purpose. Records must be kept of all medication received into the home. Medication reviews must take place to establish changing medication needs. To ensure the protection of service users, staff must (where necessary) receive futher training to develop their knowledge and understanding of the adult protection procedures. All areas of the home used by service users must be kept in a good state of repair, clean and reasonably decorated. A review of the staffing levels must take place, to ensure that there is at all times staff in sufficent numbers, to meet the current and changing needs of the service users. Service users records must be kept secure. J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Timescale for action 10/10/05 Previous timescale 1/3/05 not met. 2. 9 13 3. 18 18 11/8/05 As required on the day of the inspection 10/10/05 4. 19 23 10/10/05 5. 27 18 10/10/05 6. 37 17 11/8/05 As required on Page 20 Castelayn Version 1.40 7. 38 13 All hazardous substances must be stored in line with correspondig risk assessments, and secure where necessary to reduce the risk of harm to service users. the day of the inspection. 11/8/05 As required on the day of the inspection. Previous timescale 17/11/04 not met. 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 Good Practice Recommendations Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 Castelayn J55 S2946 Castelayn V237074 110805 UI Stage 4.doc Version 1.40 Page 22 - 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. 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