Inspection on 13/02/07 for Castle Dene

This inspection was carried out on 13th February 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Castle Dene 20/10/08

Castle Dene 05/10/07

Castle Dene 19/01/06

Castle Dene 16/09/05

Castle Dene 23/02/05

Castle Dene 07/09/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Castle Dene Wilton Village Redcar TS10 4QY Lead Inspector Val Daly Key Unannounced Inspection 13th February 2007 09:30 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 Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Dene Address Wilton Village Redcar TS10 4QY 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) 01642 454556 01642 430686 Mr Steven Hudson Mrs Jillian Wooding Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Castle Dene is a care home for older people and is registered under the Care Standards Act 2000 to provide accommodation and care for up to 27 elderly people. The home is situated in a village location. It is on the edge of the village, surrounded by a large grassy area and woodland and provides a minibus service to facilitate outings. The home offers a choice of lounge and dining areas and residents can choose to eat their meals in a dining room or their own rooms. Menus cater for the likes and dislikes of individual residents. Residents are able to personalise their own rooms and relatives and friends are welcome to visit at any reasonable time. Woodside is a care home adjacent to Castle Dene. It is registered under the Care Standards Act 2000 to provide accommodation and care for up to 6 elderly people. Fees are £370.00 per week. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was completed by a Regulation Manager and an inspector over one day. As a key inspection, all of the key standards were examined. A tour of the home took place, residents records were examined, records including accidents, complaints and menus were looked at and three residents, two members of staff, the manager and deputy manager were engaged in discussion about life at Castle Dene. The Commission for Social Care Inspection sent a number of questionnaires to the home for residents and relatives to complete. Eleven were returned from residents and relatives. They included comments such as ‘staff are always available’, I always find someone to talk to’, I don’t have any complaints’, ‘very happy overall’, ‘staff are caring, happy and cheerful’, ‘some residents need more supervision’. What the service does well: What has improved since the last inspection? Since the previous inspection ‘Woodside’ has been opened. It is a five bedded home, being converted from the previous homeowners private dwelling. The home is light airy, very comfortable. There is one bedroom on the ground floor and stairs up to the first floor where more bedrooms are situated. The lounge has an open aspect towards the gardens and extensive land. The kitchen and dining areas are domestic in nature giving a cosy, homely feel. Since the previous inspection resident meetings are held on a more regular basis. The manager or deputy manager acts upon any issues raised. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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 Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have had their needs assessed prior to admission to the home to ensure their needs can be met. EVIDENCE: Three sets of documentation were examined and they included the care manager’s assessment prior to admission to the home. The home manager then visits the potential service user that their needs can be met at Castle Dene. The assessment is based on activities of living and physical well being. The home does not provide intermediate care. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. All staff that administers medication must receive training and be competent to carry out the task to ensure the safety and well being of the people who use the service. EVIDENCE: Three care files were examined and they each contained an individual plan of care. Whilst all the information was in the individual resident’s documentation, in two cases the needs/problems were mixed up with the assessments. The plans were evaluated monthly but each identified area of need was not evaluated separately. Annual reviews from Social services are held with residents and relatives being invited to attend. The documentation showed that the resident’s health care needs were being met. Risk assessments are in place where needed. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 10 Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. At the time of the inspection there were no residents who managed their own medication. The majority of staff has received training in the administration of medication. This was confirmed in staff training records and during staff interviews. However during the inspection a member of staff was observed administering medication in Woodside and the homes policy and procedure was not carried out. The member of staff said she had not received training. Three residents were spoken to during the inspection; they all said the staff respected their privacy. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle. The meals provided offer a good balanced diet. EVIDENCE: There was documentation available to show that activities take place in the home, bingo, dominoes, keep fit, aromatherapy, and manicures, and music afternoons, church services. Whilst the residents in the main house were satisfied with the activities, three of the residents in Woodside, the new house said that they would like more to do. The manager said that the residents in Woodside are invited to join in with the activities in the main house. Up until the end of December 2006 the home had their own minibus and small groups of residents were taken out regularly. On the day of the inspection the proprietor said he was going to purchase a people carrier to enable residents to go out again in the better weather. Family and friends visit at any time Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 12 The menus showed that a variety of home cooked food is offered to the residents. There are choices for every meal and residents also said that if they didn’t like any of the food on the menu the staff would make something else for them. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Three residents interviewed said that they would be comfortable speaking to a member of staff if they had any concerns. The home has a complaints policy and procedure in place. Where a complaint had been made there was documentation to show that the complainant was happy with the outcome. There was evidence in the staff training file to show that staff had received training in Adult Protection’ and that this is a rolling programme. During interviews with staff they were aware of the procedure to follow in the case of suspected abuse. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and warm, offering the people who use the service a homely environment in which to live. However there were two maintenance issues, which need to be addressed, which could compromise the health and safety of the people who use the service. EVIDENCE: A tour of the home was carried out. Resident’s bedrooms contained personal possessions and were comfortable and homely. Maintenance certificates were in place and up to date. The home was clean and odour free. However on the day of the inspection the hairdresser was using an area on the first floor. There was an extension for plug sockets in the corridor and trailing wires. The manager said that she would ensure this practice would change. Also in one resident’s bedroom the call bell wire was trailing across the floor, which was a tripping hazard. The manager said she would have the wire fitted around the room. Since the previous inspection Woodside has opened. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 15 This is a newly converted home for five residents. The building is very close to the main home and laundry and kitchen facilities are shared. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs in the home are trained and skilled, however they need to be constantly in sufficient numbers to support the people who use the service. EVIDENCE: The home has a rota in place, which shows a skill mix of staff being on duty on each shift. The member of staff covering the teatime shift was not on the recent rotas. The manager said that there had been a reduction in resident numbers mainly due to residents moving to Woodside. This had resulted in a reduction of staff on the teatime shift. The provider of the home agreed to re instate this shift back into the rota. It was also noted that there was no domestic assistance for Woodside, neither did the member of care staff working get a break away from the residents. After further discussion with the provider it was agreed that domestic assistance would be put in place and the manager or deputy would relieve the carer in Woodside to enable them to have a break. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 17 There is a policy and procedure in place for the recruitment of staff. Staff records showed that the required information, references and CRB checks were in place prior to staff commencing work in the home. Staffs receive induction training, however this could be developed further to run alongside ‘Skills for Care’ induction programme. The home has a training plan in place and since the previous inspection staff had undertaken training in many areas such as NVQ 2, Adult Protection, Fire Safety and Advanced Care Practice. More than 70 of the carers have undertaken and completed NVQ level 2 or above, which is over the required number of 50 . Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The quality assurance system needs to be developed further to include the views of residents and relatives on the service. EVIDENCE: The manager and deputy manager have worked in the home for several years. They are both are well qualified in care and management and work together to ensure a strong management team. The home undertakes an annual audit of the service they provide however this could be developed further as the previous questionnaire only covered some of the areas of the service. Residents and relatives need to give views on all aspects of the service. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 19 Resident meetings are also held regularly and minutes are kept. From this information the manager formed an action plan to resolve the issues raised, which were more variety of food at tea time on Sundays and choice of when to get up in the mornings. Three residents spoken to during the inspection said they were happy living in the home. The manager is also available to speak with residents and staff on a daily basis. The home has health and safety policies and procedures in place. Training files showed that staff has received training in health and safety Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 20 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 21 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. 1. Standard OP9 Regulation 13 (2) Requirement All staff who administer medication must have received training and be competent to carry out this task. All areas of the home to which service users have access must be free from hazards. Staff must be competent, experienced and in sufficient numbers for the health and welfare of the service users. Timescale for action 30/05/07 2. 3. OP19 OP27 13 (4) (a) 18 (1) (a) 30/05/07 30/05/07 Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP30 OP33 Good Practice Recommendations In resident’s documentation, assessments and needs/problems should be clearly set out. Staffs receive induction training, however this could be developed further to run alongside ‘Skills for Care’ induction programme. Quality assurance should be developed further to enable residents and relatives to give views on all aspects of the service. Castle Dene DS0000060986.V322297.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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