Inspection on 01/05/07 for Castle Grange

This inspection was carried out on 1st May 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 Grange 16/06/08

Castle Grange 06/06/06

Castle Grange 26/01/06

Castle Grange 01/09/05

Castle Grange 05/01/05

Castle Grange 02/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Castle Grange 9 Haymans Green West Derby Village Liverpool Merseyside L12 7JG Lead Inspector Pat Kearney Key Unannounced Inspection 09:30 1st May 2007 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 Grange DS0000025093.V331950.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 Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Grange Address 9 Haymans Green West Derby Village Liverpool Merseyside L12 7JG 0151 226 5676 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) Southern Cross Operations Limited vacant post Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 41 Nursing and 8 Personal Care in an overall total of 41 One named person under 65 years of age may be accommodated. Date of last inspection 6th June 2006 Brief Description of the Service: Castle Grange is a large modern purpose built care home providing 31 beds for nursing care and 8 beds for personal care Older people. One bed can be used by a named person under the age of 65. The home is located near to West Derby village close to shops, churches and other amenities with public transport links to the city centre 5 minutes walk from the home. The care home became part of the Southern Cross Healthcare organisation in July 2005. Accommodation is provided on three floors with lift access to each floor. There is a pleasant garden to the rear of the premises and shrubbery to the front. Car parking facilities are located to the front of the building. All rooms are single Six rooms have en-suite facilities and 38 rooms are at least 12 sq metres in size. There are two lounges, one of which is larger and which provides a smoking area and the other lounge which is smaller and used as a quiet lounge. There is a large dining room with patio windows overlooking the rear garden. Fees charged as of May 2007 are Nursing £405 50 per week Personal care £315.50 per week Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on 1st May 2007 and took place over six hours and was unannounced. Discussions were held with the residents about their experience of living at Castle Grange. Seven service users/ relatives surveys were sent to the home prior to the inspection seven were returned. The views of health and social care professionals who visit the home were sought through questionnaires and telephone calls and discussion on the day of the inspection. A range of documentation was examined this included service users care plans, risk assessments menus various dietary charts residents personal allowance records, staff personnel files, training records Health and safety and maintenance records. A tour of the building took place. Discussions were held with the Acting Manager Regional Manager Qualified Nurses, care staff, and activities coordinator about the management and daily working practices of the home. There have been no complaints made to C.S.C.I. since the last inspection. What the service does well: Residents, relatives health and social care professionals all confirmed that residents are well cared for, treated with dignity and respect at all times and that their assessed needs are met. Residents said that the “staff were kind and caring” An activities organiser is in post and works hard to ensure that residents who wish to participate in individual or group activities are supported to do so. A range of activities is supported both inside and external to the home. Residents individual needs are fully assessed prior to admission to the home and specialist aids, adaptations or communication aids are obtained to meet the residents individual needs. The particular and individual cultural and diverse needs of residents are assessed and met. Questionaires were completed by a range of healthcare professional who confirmed that the home works closely with them and are confident that “ the staff at the home are committed to providing the best possible care for the residents” Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 6 The home has a complaints procedure. Seven complaints had been made in the past twelve months all of which were of a minor nature and had been dealt with immediately. No complaints have been received about Castle Grange by CSCI. Castle Grange has a robust recruitment and selection policy which protects residents from harm or abuse. The home has a range of policies and procedures which have been approved by C.S.C.I as meeting all the National Minimum Standards these policies and procedures are fully implemented at the home by the acting manager which protects the health safety and welfare of residents and staff. What has improved since the last inspection? What they could do better: The Acting manager has informed the Regional Manger that she intends to leave the home when another manager has been appointed. It is important that the new manager is appointed to ensure that the improvements made to the home are maintained and that person is registered with C.S.C.I Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 7 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 Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2.3.4.5. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Prospective residents have the information, they need to make an informed choice about the home, and the holistic needs assessment completed prior to admission confirms that the staff are able to meet specific needs of potential admissions. EVIDENCE: Since the last inspection the information for residents has been produced on audio tape and compact disc to assist people with visual impairments literacy and other health related issues that make reading difficult. The Regional Manager confirmed that translation into a range of languages could be facilitated to meet the individual needs of people. During the inspection there were two telephone enquires made about a place at the home from family members, they were actively encouraged to visit the home at anytime “No need for an appointment” said the acting manager. A family did visit the home during the inspection they were welcomed and shown around the home by one of the qualified nurses. It was observed that the Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 10 questions they asked were answered fully and they were given the corporate information pack containing The Statement of Purpose and Service User Guide for Castle Grange. At the end of the visit they were informed that they could telephone if they had any further questions they wanted to ask. Social care professionals spoken to as part of the inspection process confirmed that potential residents were able to visit the home prior to making a decision to move into the home on a permanent basis. A relative spoken to confirmed that the admission process for their relative had been conducted in such a way that the service user felt welcomed and the process was not rushed with staff taking time to “Support them to become familiar with the layout of the home” The acting manager confirmed that all service users have been issued with a contract of their terms and conditions by Southern Cross Healthcare copies were available for inspection. All new residents receive a full comprehensive needs assessment prior to admission to the home usually completed by the acting Manager or one of the qualified nurses. Individuals and/ or their family members together with relevant members of the multi agency team are encouraged to be part of the information gathering process. Evidence was available to identify that issues of equality and diversity are addressed as part of the assessment process. Specialist services have been involved and communication, eating and mobility aids have been obtained to meet the specific needs of individuals. Discussions with the acting manager demonstrate that she has a good understanding of equality and diversity issues and how important it was to address these issues in meeting the specific needs of residents. She gave examples of what actions she and the staff team had and would take to ensure the residents specific individual needs would be met. Examples included additional training for the staff group to raise awareness on specific individuals needs and how those needs can be met. Accessing specific aids and adaptations to facilitate communication and maximise the independence of residents. No intermediate care is provided by the home. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A holistic plan of care is in place which identifies and ensures that the health personal, religious and cultural needs of individual residents are met. Medicines are managed appropriately so ensuring the health safety and welfare of resident. Residents are supported with respect for their privacy and the maintenance of their dignity, at all times. EVIDENCE: All residents in the home have an individual comprehensive care plan, which is completed on admission to the home, reviewed by the qualified nurses on a monthly basis, and any changing needs recorded. A comprehensive review is conducted on a six monthly basis with service users and or their relatives or representatives involved in the process. Daily health records are recorded daily for each resident this includes any critical incidences plus any visits from GPs, specialist nurses etc. Care plans include the health and care needs of residents. Most residents are registered with a local GP practice and the home receives good support from the doctors and various members of the community health teams including the district nurses, community dietician and speech therapist A record is maintained of any contact the individual resident has with health care Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 12 professionals and notes are made in the daily records, of any health related matters. The changing health needs of individual residents are identified and the relevant healthcare professional consulted. The named community nurse surveyed as part of the inspection confirmed that “the staff follow precisely the treatment plan and any changes are recorded and they are contacted along with the relevant G.P. to reassess the changing needs” The home has good links with the continence adviser and has made arrangements with a private chiropodist to visit the home on a regular basis. A local dentist will provide treatment for residents who are able to attend the surgery. Questionaires were completed by a range of healthcare professional who confirmed that the home works closely with them and are confident that “the staff at the home are committed to providing the best possible care for the residents” Discussion with residents and their relatives spoken to as part of the inspection said that they were “ happy at the home” and provided with the care and support they needed and that the “staff were kind and caring” All residents spoken to or surveyed as part of the inspection said that the staff treat them with dignity and respect and that they are able to spend time alone and that the staff respect their privacy. There was an excellent example of good practice in meeting the very specific diverse and individual needs of a resident. The resident had been consulted and involved and the residents family had provided invaluable advice to staff to facilitate meeting the assessed needs of the resident Specialist services had been involved in providing advice, support and training for the staff group. The acting manager had obtained the appropriate equipment to further aid and improve communication between the staff and resident. Staff were escorting the resident to a weekly social club where other people with the same disability meet so help reduce the persons social isolation. Relatives surveyed confirmed that every effort had been made to make their relatives feel involved and included n the life of the home and that individual needs are identified and met. Both residents and their relatives confirmed that they are always treated with dignity and respect by the staff group and stated that they found the acting manager helpful and approachable at all times. One resident at the home self medicates risk assessments have been completed. All other medication is administered by the nurses in the home. The protocols for the receipt, storage, disposal, and documentation of medications in the home meet the required standards. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 13 Discussions with the local pharmacist who supplies the home with medication said that they had no concerns about the homes practices and were confident that any issues or changes that occur they would be discussed with the pharmacist. The acting manager confirmed that following admission to the home managed sensitively and responsive to the individual resident and /or their family, information is collected and recorded in the care plan about their wishes and choices at the time of death. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 14 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 excellent This judgement has been made using available evidence including a visit to this service. Residents enjoy a range of activities that reflect their own choices, preferences and lifestyle; they are consulted about the day-to-day running of the home and receive a wholesome, balanced diet. EVIDENCE: The initial assessment documents contain information about the previous lifestyle of residents, their likes and dislikes and their choices, preferences, hobbies and interests. An activities organiser is in post and works hard to ensure that residents who wish to participate in individual or group activities are supported to do so. A range of activities is supported both inside and external to the home. Publicity was achieved from a local newspaper around the regional Southern Cross annual Easter Bonnet parade which one of the Castle Grange residents had won. Southern Cross has a number of homes in the area and Castle Grange can borrow a mini-bus to support trips out. During the year tea dances and a Summer Ball had been arranged and residents had participated wearing ball gowns and tiaras. This had been Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 15 organised in partnership with other Southern Cross homes and a local primary school with the schools pupils acting as waiters serving the refreshments. There was photographs displayed in the home demonstrating that the home marks various festivals throughout the year. These have included Chinese New Year, St David’s St Patrick’s and St George’s day the home is decorated appropriately to mark the particular event with culturally sensitive entertainment and food provided. During the inspection residents were enjoying a video of the Irish singer Daniel O’ Donnell and one resident told the inspector that she was hoping she would be able to go to his forthcoming concert to be held in Liverpool accompanied by a member of staff commenting “I know the staff will make every effort to get me there” Staff are in the process of developing a “Life story book with the collaboration of residents and their relatives. Staff at the home are also in the process of completing a course called “Yesterday Today and Tomorrow” which will assist staff to further develop a increased person centred approach to providing care to the residents. The course includes addressing issues of diversity and culture relevant to each individual resident. Staff interviewed as part of the inspection said they had found the courses very interesting and had raised their awareness of the individual needs of the residents. Ministers of religion visit the home and conduct services for the service users. Some of the residents at the home were looking forward to exercising their right to vote in the forthcoming local elections which were due to take place in the week of this inspection. The Acting manager confirmed that a small group of the residents were being taken by staff to the local Polling station The dining room has been redecorated the ceiling tiles replaced and new curtains purchased which has increased the overall brightness and homeliness in the room. Southern Cross has invested in a new menu planning software package called “Nutmeg” This package has an extensive range of menus including a wide selection that would meet the dietary needs of people from various racial groups. One of the key advantages of this software package is that it provides a detailed breakdown of the nutritional value of each meal which supports staff in providing a nutritious and balanced diet to residents. The acting manager was able to demonstrate her knowledge and understood that some racial groups required food to be prepared in a specific way. She confirmed that she would seek advice from leaders of specific groups based in Liverpool if she was unsure. Confirming that she was able to purchase food for specific groups from specialist suppliers contracted to Southern Cross. If an Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 16 emergency arose she would purchase food to meet dietary and religious needs from the range of restaurants or take away facilities available in Liverpool. The acting manager has introduced two sittings at each meal with those service users needing assistance by staff being served first. The inspector observed the service users being assisted by staff in a discreet and unrushed manner. Taking time and engaging in conversation with service users. The dining room was calm and conducive to making mealtimes a social event. Since the last inspection the quality of meals served at the home has been maintained. A four week menu has been implemented with a choice of food provided at each meal salads are also available. A choice of desserts are also available. All residents unless contraindicated for health reasons are offered a glass of sherry at lunchtime. Residents told the inspector that they enjoyed “The Tipple very much” The presentation of the soft diets has improved with meals being presented in an appetising way. When asked residents “said they enjoyed their food” other residents who have a soft diet said they were able to choose which meal they wanted from the menu and it would be prepared for them The acting manager has introduced charts which identify the daily food intake of all service users and a food audit that tests the residents’ satisfaction at every meal. The chart should include suppers and refreshments served. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 17 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): 16.17.18. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Complaints are treated seriously and the legal rights of residents are protected. Staff are trained in the recognition and reporting of abuse which protects residents from harm or abuse. EVIDENCE: The home has a complaints procedure that is made available in the statement of purpose and the service user guide. Seven complaints had been made in the past twelve months all of which were of a minor nature and had been dealt with immediately. No complaints have been received about Castle Grange by CSCI. Two anonymous letters of concern have been received by C.S.C.I. The first was investigated during a random inspection in November 2006 no evidence was found to support any of the issues raised in the letter. A further letter was received in April 2007 highlighting a range of issues similar to those raised in November. This letter was fully investigated as part of this key inspection. Interviews were held with residents and or their relatives, health and social care professionals involved with the home again no evidence was found to support any of the issues raised in the letter. All of the residents are listed on the Electoral Register and have the opportunity to vote in local and national elections. Policies and procedures are in place to support staff in recognising and reporting any concerns about the inappropriate treatment of residents. Staff Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 18 have been trained in the Protection of Vulnerable Adults (POVA) procedures and this is updated from time to time. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 19 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): 19.20.21.22.23.24.25.26.Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of décor in this home is good with evidence of continuing improvements, through ongoing maintenance and planning. The home presents as a homely, safe and comfortable environment for the residents to live. EVIDENCE: There is a programme of ongoing maintenance at the home which the handy man undertakes. The lounges were warm bright comfortable and clean and odour free. The dining room which has been redecorated and new ceiling lights purchased was pleasant bright and overlooks the newly extended patio area. Tables were set with crockery and cutlery fresh laundered tablecloths. There have been a number of improvements to the home since the last inspection, residents confirmed that they had been involved in the choice of wallpaper for the corridors which are currently in the process of being redecorated. A tour of the building confirmed the standard of hygiene has been maintained Curtains in the service users bedrooms and corridors were looking and smelling Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 20 fresh and clean. In the lounges curtains have been replaced which has increased the brightness and light in the lounges. The laundry at the home was clean, well organised and the range of equipment was suitable to manage the large amount of washing and drying incurred each day. Service users bedrooms had been thoroughly cleaned and /or decorated with carpets being replaced in some bedrooms. The majority of the service users bedrooms were personalised with their own memorabilia All bathrooms and toilets had liquid soap and paper towels. There are a range of aids and adaptations available at the home to meet individual service users assessed needs. These include bath aids, specialised crockery, cutlery and non slip plate mats. The flooring between the dining room and serving hatch was in need of repair the handyman was in the process of repairing the damage during the inspection. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 21 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 good This judgement has been made using available evidence including a visit to this service. Service users needs are met by the number and skill mix of staff who are provided with a range of specialist and mandatory training to ensure the ongoing and changing needs of the service users are met. EVIDENCE: There is always at least one first level Registered Nurse on duty who is assisted by health care and ancillary staff. Staff spoken to had a good knowledge of the service users assessed needs and how those needs would be met. All staff spoken to were enthusiastic about their work. Southern Cross has a robust recruitment and selection policy. A sample of five staff files were examined during the visit. Each contained a completed application form, two references and confirmation of Protection of Vulnerable Adults (POVA) two newly recruited staff had a P.O.V. A first and a full Criminal Records Bureau (CRB) check had been applied for. Separate files are kept to store evidence of training and records of staff supervision. The new members of staff recently recruited had received Adult Protection Training since taking up post. There was evidence of induction training on the files of more recently appointed staff and the home has a training programme in place to support essential and ongoing developmental skills for both the qualified nurses and health care assistants. There was evidence to support that issues of disability had been addressed appropriately for staff. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 22 Of the 21 health care assistants 7 hold N.V.Q Level 2 Six other staff are working towards the award three of which have almost completed the award. Newly recruited staff who currently do not hold the Level 2 award have confirmed with the manager they are willing to commence the award. Residents, relatives health and social care professional interviewed confirmed that staff “know the residents needs and always treat people with dignity and respect” Residents said that the staff group were “kind and caring” and relatives said they are kept informed by staff of any changes in their relatives condition. One relative commented “that they felt their relative was safe and well cared for “ Staff interviewed showed a good understanding of equality and diversity issues, which included recognising religious and cultural festivals celebrated in Liverpool and ensuring that these various cultural events are marked and celebrated within the home. Another example given was that the individual dietary needs of residents are met. The manager and qualified nurses are in the process of completing “Yesterday Today and Tomorrow” training programme which is a person centred approach to the care of residents. This training is to be cascaded to all staff at the home. This person centred initiative will identify the specific and individual needs of residents which will ensure that equality and diversity issues are addressed when a new resident is admitted to the home. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 23 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): 31.32.33.34.35.36.37.38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The acting manager is supported by the qualified nurses in providing clear leadership at the home which ensures that service users health safety and welfare promoted and protected. EVIDENCE: The Acting Manager is a Registered General Nurse with many years experience working with the service user group and has been in post since the end of March 2006. There have been a number of noticeable improvements at the home since her appointment. Service users, relatives, staff and health and social care professionals contacted as part of the inspection process said that . “ Care standards have improved” and the manager is “approachable and friendly”. However, the acting manager has informed the Regional Manager of her intention to leave Castle Grange when her successor has been appointed. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 24 The acting manager has a good understanding of equality and diversity issues and evidence of how these issues are addressed and integrated into the management and practice within the home were evident and have been documented previously in the report. The Regional Manager who was present for part of the inspection is a regular visitor to Castle Grange. Residents, relatives and staff knew her by her first name. The Regional Manager assured the inspector that an advert to recruit a new manager had been placed in the local press. She also said that Southern Cross had recently appointed a Project Manger who would if recruitment was proving unsuccessful would be placed at the home on a temporary basis until a manager had been appointed. Castle Grange has a range of policies and procedures which are fully implemented by the acting manager and ensure the health safety and welfare of residents and staff. Throughout the visit staff were observed to get on with their work without constant reference to the manager for direction or approval. Staff meetings are held regularly and minutes are kept. Residents and relatives were confident to approach the manager and their concerns would be addressed and were complimentary about the ways in which care and support are provided. The records seen and observations of the interactions between staff and residents, the range of activities provided and the efforts made to ensure residents were supported in a calm and unhurried way, and from the comments made by residents, relatives, staff and health and social care professionals it is clear that Castle Grange is run in the best interests of residents. During the week of the inspection Southern Cross was in the process of completing the annual financial audit. On completion no financial irregularities were found. Southern Cross, who own Castle Grange act as appointee for a number of residents. The home’s administrator receives a cheque to cover the personal allowances for the residents concerned and pays them either the full amount or smaller sums of money as and when they require it. Detailed records of income and expenditure for individual records are maintained and are thorough. Southern Cross Healthcare have rigorous quality assurance processes in place which include regular service user surveys to establish the level of service users satisfaction. The regional manager visits regularly and conducts an audit of the home copies of her findings are forwarded to the C.S.CI. There is a corporate expectation that the manager “walks the walk” and tours the building each day on duty this is recorded Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 25 All health and safety checks had been regularly completed and recorded in the appropriate Southern Cross Healthcare documentation. The home’s certificates of insurance and maintenance for machines, fire equipments, lift, hoists were in date and valid. Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 26 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. Extracts may not be used or reproduced without the express permission of CSCI Castle Grange DS0000025093.V331950.R01.S.doc Version 5.2 Page 29 - 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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