Inspection on 14/03/06 for Castelayn

This inspection was carried out on 14th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 11/08/05

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 Mr Rob Curr Unannounced Inspection 10:00 14 March 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Castelayn Address 2 Leighton Drive Sheffield South Yorkshire S14 1ST 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) 0114 239 8429 0114 239 8216 www.sheffcare.co.uk Sheffcare Limited Ms Valerie Wait Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (4), Physical disability of places over 65 years of age (4) Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 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. 11th August 2005 Date of last inspection 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 DS0000002946.V279389.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 10.00 a.m. and lasted 2 hours. A second inspector – Janis Robinson was present during the inspection, which lessened the time on site. Progress of requirements and recommendations were made during this visit. The main inspection method was observation of routines and the quality of interaction between staff and residents. Two team leaders were present during the inspection so the inspectors also discussed practice at the home with them. The residents were very helpful during the inspection process, offering an opportunity to talk about what life was like at the home. In all – 8 residents and 6 staff members were spoken to. The team leaders and administrator were helpful and assisted the inspectors throughout the visit. What the service does well: What has improved since the last inspection? The Service User Guide had been reviewed. Further staff had undertaken training in Adult Protection. The team as a whole have worked hard to maintain and enhance the service delivery. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3 and 6. Resident’s needs were assessed prior to admission. Residents and their relatives were fully involved in the assessment process, so this ensured that the home was able to meet their needs. EVIDENCE: Copies of full needs assessments were in the residents files. All the relevant information from the assessments had been built into the care plan. There was also a ‘terms and conditions of occupancy. ’ which highlighted contractual arrangements for accommodation and services.. Residents said that they had been invited to view the home and attend ‘a variety of meetings’ prior to moving into the home. Staff training records indicated that they had undertaken relevant training required to assist them in caring for the people that reside at Castelayn. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 and 11. The information within the care plans was very clear. Health care was monitored and care plans were reviewed. This ensured the well-being of the residents. A range of health care professionals visited the home to assist in meeting the needs of the residents. Residents could choose their GP and could see them in private so that their privacy and dignity was respected. All medication administered was signed for. Resident’s wishes regarding dying and death were recorded. EVIDENCE: The care plans were checked. They were comprehensive and contained detail of the action required by staff to meet the residents needs. The plans contained records of health assessments such as moving and handling. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 10 All the residents said that their health needs were met. Four residents said that they were ‘more than happy’ with the care they received. Medication Administration Records (MAR) were checked. Staff had signed to indicate that medication had been administered. Staff were observed respecting residents privacy by knocking on bedroom doors before entering and closing bathroom and toilet doors when in use. During the activities session that was taking place, staff were seen and heard treating residents kindly and respectfully. There was a ‘nobo-notice board’ in a public area that identified some personal information, including bathing and discharge information. This could compromise the confidentiality of the residents concerned. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15. The home creates a varied programme of social and recreational activities. The routines at the home were flexible. The home had an open visiting policy in order to develop and maintain good relationships with resident’s friends and relatives. Residents were enabled to make choices. Phone calls can be made without permission in a private area. All the residents were happy with their personal bedroom. There was a clear choice of menu. EVIDENCE: Residents were seen to walk freely around the home. One resident said her friends could visit ‘when ever they wished’. There was a programme of activities on display, which included quizzes, music and movement, bingo and dominoes. Preparing for the lunchtime meal, staff were heard encouraging residents to make choices. There were mixed views in relation to the catering services, although the manager had convened a meeting with the residents to discuss issues around catering. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16 and 17. Residents were aware of how to make a complaint and were confident that they would be listened to and their legal rights are protected. EVIDENCE: The comments and complaints procedure was available in the foyer, which contained relevant information and provided the reader with details of who to contact outside the home, to ensure complaints were taken seriously. Copies of this procedure were also placed in each room. The residents and staff all stated that they had confidence in the homes manager. They said that she would listen and respond to any concerns they raised. All the residents spoken to said they felt ‘happy and safe’ at the home. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19,20,21,22,23,24, 25 and 26 The home was clean and well maintained. Communal areas were homely, and were well decorated. Sufficient bathing facilities were provided. The bedrooms seen were personalised by residents and their relatives. The home was free of any offensive odours. Systems for the control of infection were in place. A call system was available in all rooms used by the residents so that they could summon assistance at all times. EVIDENCE: One inspector carried out at tour of the home. All of the residents spoken with were happy with their bedrooms and the furniture provided. The home was well decorated and maintained, to provide a comfortable environment for the residents. A resident activated the ‘call system’; the staff attended this request for assistance immediately. At the base of some of the double doors on corridors, there was a ‘well’ created by the floor covering creating an uneven surface. The team leader was aware of this issue and immediately took action to remedy this. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30. Sufficient staff were provided to meet the needs of the residents. The manager could identify the training needs of the staff group. EVIDENCE: Three residents felt that there not always were enough staff on duty during the day to care for their needs. 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. The organisation delivers an internal ‘bank staff’ system. Three residents said that the staff were ‘as good as gold’ and ‘they couldn’t do more for us’ There were staff vacancies including a team leaders post. This has resulted in some staff not receiving supervision at the recommended intervals. A group of staff were currently undertaking National Vocation Qualification (NVQ level 2) in direct care. Staff spoken to confirmed that they received more than 3 days paid training each year. The organisation maintains a training matrix, which enables the manager to monitor the training needs of the staff. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33,36, 37 and 38. There has been change in registered manager since the last inspection. The resident’s finances and personal monies were well managed. There was a quality assurance system in place, which gave residents and visitors an opportunity to express their views and suggest ways in which the service may be improved. Health and safety checks were in place to ensure residents were safe. EVIDENCE: The staff stated that although there had been change of manager, this had been a positive experience. The manager ‘has communicated and shares all information with us’ she has ‘an open door policy’. This clearly benefits the residents, their relatives, and representatives. Staff supervision systems were in place to ensure best practice was maintained. Not all staff had received supervision at the recommended intervals. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 16 All records were securely stored. Fire records were maintained of fire alarm tests. All staff spoken to confirmed that they had undertaken a fire drill practice. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 17 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 18 X 2 3 3 3 3 3 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 3 3 3 X 3 2 X 3 Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 18 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. 2. 3. Standard OP10 OP19 OP27 Regulation 12 13 18 Requirement Information related to residents must not be displayed in public areas. The uneven floor surface at the base of the identified doors must be made level. A review of the staffing levels must take place, to ensure that there is at all times staff in sufficient numbers, to meet the current and changing needs of the service users. Timescale for action 14/03/06 14/03/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP36 Good Practice Recommendations The manager should continue to establish whether the catering services are meeting the needs of the residents. All staff should receive supervision at the recommended intervals. Castelayn DS0000002946.V279389.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sheffield Area Office 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 DS0000002946.V279389.R01.S.doc Version 5.1 Page 20 - 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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