Inspection on 18/04/07 for Castle Grange

This inspection was carried out on 18th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Castle Grange 28/09/06

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

CARE HOMES FOR OLDER PEOPLE Castle Grange Ing Lane Newsome Huddersfield HD4 6LJ Lead Inspector Jacinta Lockwood Key Unannounced Inspection 18th April 2007 09:35 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 DS0000067874.V336505.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 DS0000067874.V336505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Grange Address Ing Lane Newsome Huddersfield HD4 6LJ 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) 01484 223439 01484 223440 anne.ashton@kirklees.gov.uk www.kirklees.gov.uk Kirklees MC Care Home 40 Category(ies) of Dementia (40), Dementia - over 65 years of age registration, with number (40) of places Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can only admit service users over the age of 55 years. Date of last inspection 28th September 2006 Brief Description of the Service: Castle Grange was registered with the Commission for Social Care Inspection in May 2006. It is a purpose built, two storey property providing single bedroom accommodation, all of which have en suite shower, toilet and hand-washing facilities. The home is situated in the Newsome area of Huddersfield, close to local shops, public houses, post office and public transport. Castle Grange provides personal care accommodation for up to forty service users with dementia type illnesses. The majority of service users are aged over 65 years, however the home is able to accommodate service users from the age of fifty-five years. Thirty places are provided for long-term care. Ten places for respite care are situated on the upper floor of the home. A passenger lift and stairs link the ground and upper floors. Accommodation is provided in four, ten bedded suites. Each suite has a kitchenette, open plan dining and lounge areas and assisted bathing and toilet facilities. There is a meeting/activities room on each floor. The activities/meeting room on the first floor has enclosed hairdressing facilities. A separate smokers’ lounge is available on the ground floor with extractor fans fitted and access to secure grounds. There is secure outdoor space for service users, accessible to those in wheelchairs or with other mobility difficulties. A loop system is available in the lounges and reception area to assist people with hearing impairment. The Commission for Social Care Inspection was informed on 31.01.07 that the fees were £508.29 per week. Additional charges include hairdressing, personal clothing/toiletries, transport, chiropody and optician and dentist, if not free. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide, together with the latest copy of the Commission for Social Care Inspection report. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection one inspector visited Castle Grange on 18.04.07. the visit started at 09:35 and ended at 17:40. At the time of the visit there were 38 people staying at the home. During this visit the inspector made observations, spoke with five service users, three visiting relatives, the co-ordinator in charge and four members of staff. Before the visit, to enable people to comment on the service provided, surveys were sent to eleven people who were staying at the home, one was returned and had been completed by the person’s relative; ten relatives’ surveys were sent; six were returned completed and eight health and social care professional surveys were sent out but none were returned. During the inspection records were sampled including the care records of people living at the home, activities, medication, monies, staff recruitment and training records, health and safety information, policies and procedures. A tour of the building was made including some bedrooms and garden. Observations were also made. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection; for example, notifiable incident reports when service users are involved in an accident or incident and monthly management visit reports completed by a senior care manager from the service following a visit to the home. The inspector would like to thank all those who contributed to the inspection process. What the service does well: Castle Grange is a modern, purpose built care home, which provides a comfortable and homely environment for people living and working there. The home provides sensory stimulation for people within the well maintained and attractive garden, which also provides a secure place for people to move around freely, and within the home where there is a sensory room and reminiscence areas in the lounges. Relatives are satisfied with the care provided. Comments were received such as Castle Grange “Promotes a happy and safe atmosphere with patience and great care for the residents who in some cases can be very challenging” and Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 6 “The staff at Castle Grange have done a superb job of caring for my (relative) who has had a traumatic year”. Another relative said “Visiting (relative) at Castle Grange is a good experience”. Staff have a warm, caring and patient approach to the people they support and people living at the home were comfortable and relaxed with staff. Relatives feel that staff and management at the home are approachable and professional in their approach. What has improved since the last inspection? What they could do better: People’s clothing looked well cared for, but there is no dedicated laundry person over seven days which means that care staff have to deal with laundry on some days. This means that they are not then available to people living at the home, therefore, staffing arrangements in the laundry should be increased. Although some staff have received fire safety training and further training is planned, night staff at Castle Grange have yet to receive fire safety training. The inspector was informed that this had been arranged of 03.05.07. The service provider must ensure that all staff are trained in fire safety, including involvement in a fire drill, so that, in the event of a fire, they know what action to take. Castle Grange DS0000067874.V336505.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 DS0000067874.V336505.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 DS0000067874.V336505.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): 3, 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Before someone is admitted to the home an assessment of need is obtained and if the home can meet the person’s needs written confirmation is provided. EVIDENCE: Castle Grange does not provide intermediate care. The files of four people using the services at Castle Grange were examined. Information about people wishing to move into the home is obtained from the Community Care Assessment. The home also carries out a pre-admission assessment to support their decision-making. Following assessment, the service provider confirms, in writing, whether or not the home can meet the person’s assessed needs. If the home is able to accommodate the individual, a contract is provided. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 10 People wishing to use the service are encouraged to visit beforehand and may stay for a meal or overnight if they wish and if there is a vacant bedroom. A relative returning a survey on behalf of her husband said that she had visited the home before her husband moved there and she had received enough information about the home and a contract was provided. The home admits service users with diverse needs and from a range of social and cultural backgrounds. Relatives returning surveys indicated that they ‘always’ or ‘usually’ received enough information about the home to help them make decisions and that the home met the needs of their relatives. Castle Grange DS0000067874.V336505.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The health, personal and social care needs of those staying at the home are recorded in their individual plan. Staff take appropriate action should someone require health care input. And action is taken to promote individual’s privacy and dignity. Medication is safely managed at the home. EVIDENCE: The care records of four people living at the home were inspected. Records identified people’s needs and how these were to be met. However, where records note the person “needs assistance” or “needs some foods cutting up”, the care plan should be more specific, so that it’s clear what form the assistance should take and which foods need to be cut up, so that the information is clear and does not leave room for interpretation. (See Recommendations.) Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 12 One person’s care needs had changed and the support plan was brought up to date at the time of this visit. There was evidence that relevant healthcare professionals had been informed of the person’s current state of health and were involved. There was evidence that information and advice from healthcare professionals was reflected within the care plans. And care plans were kept under review. From surveys it was evident that relatives were kept informed and one wrote that when their relative was ill he was dealt with “in a very caring and highly professional manner” by staff at the home. Records show that people living at the home have access to health care services, for example, chiropody and dental services. Risk assessments were available and had been kept under review. However, although risks were reflected within one person’s care plan not all of the risks within the care plan had been included on the risk assessment. Although this was addressed at the time of the visit, care should be taken to ensure risk assessment documentation is fully completed. (See Recommendations.) Records were generally up to date and complete but staff completing records should ensure that the information is meaningful. For example, monitoring charts prompted staff to note the amounts of food or liquid taken by the person concerned but some entries were just ticked rather than noting the amount. Detailed records are important for monitoring purposes and action should be taken to address this. (See Recommendations.) Staff were observed to maintain and promote service users’ dignity. Personal care is attended to discreetly and in private. People have their own rooms and these are generally kept locked when not in use to prevent other people entering their private space. Bedroom doors are also fitted with alarms so that staff are alerted should someone, other than staff, open the door. At the last inspection, a requirement was made for people’s dignity to be promoted as some bedrooms had offensive odours. This requirement has now been met and none of the rooms inspected had offensive odours. This is also referred to in the Environment section of the report. Medications for three people were checked and were easily reconciled with the records, which were clear and well maintained. Medication was stored securely and drugs returned to the pharmacy for destruction were recorded. At the time of the visit there were no controlled drugs in stock. Appropriate recording systems and secure storage were available for such drugs. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home are supported to access in-house and community based activities, which cater for their individual and group needs. They are supported to make choices and maintain contact with their family and friends. Food at the home, which is freshly prepared, nourishing and well presented is served in pleasant surroundings and people can take their meals in an area of their choosing. EVIDENCE: Castle Grange has attractive, well planted grounds which people can safely access, with sensory equipment such as wind chimes, bird feeders, and tactile objects as well as seating areas. People were seen to move freely between the home and the secure grounds, which afforded them access to fresh air and sunshine. An activities person visits the home for 15 hours each week and records show that one-to-one and group activities take place. Examples of activities were colouring, dominoes, bingo, throwing hoops, beetle drive, cards and visits to a Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 14 sister home for tea and bingo. People had also been involved in making almond buns and jam tarts. One of the relatives returning a survey felt that the home ‘usually’ supported people to live their chosen life and commented that “more activities/entertainment to stimulate the resident’s minds would be appreciated”. A section of the lounges has a memory area with objects such as coins, pictures, cards and objects, which people can pick up and touch. Objects with different textures and colours were freely accessible to them. There is a quiet ‘sensory’ room with comfortable seating where people can sit and the door was open to allow easy access. Staff were seen to engage people in conversation and some people were engaged in conversation with each other. A member of staff offered to go for a walk with one of the people living at the home, but the person chose not to. Others were seen to watch the television, listen to the radio and read a newspaper. The atmosphere in the home was calm and relaxed and people living there appeared settled and contented, showing no signs of negative wellbeing. Contact is maintained with the local community and the inspector was informed that ministers of religion visit the home. Also, that links are being developed with the local school that visited the home over the Christmas period. At the time of the visit a number of people were having their hair done by a visiting hairdresser and they appeared to enjoy the experience, sitting calmly and smiling. Visitors to the home were made welcome and one visitor was able to join her husband for a teatime meal, which was positively remarked upon. The mid-day meal was freshly prepared and looked appetising and well presented. A choice of food was available and offered. And fresh fruit was freely available. One person who didn’t want to sit at the table was given finger food to eat while walking around and another was seen to take their meal in the lounge rather than the dining area. Relatives’ surveys contained comments such as “excellent food” and “good nutritional food”. People seemed to be enjoying the food and those who spoke with the inspector made positive comments about it. Staff were observed to sit one-to-one with individuals who required assistance to eat and this was provided in a skilled and patient manner with staff giving encouragement and offering choice. A previous requirement relating to the promotion of people’s dignity at mealtimes has been met. A recent Environmental Health Officer’s report noted that there were excellent systems in place in the kitchen. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Anyone wishing to make a complaint about the service at Castle Grange can be confident that his or her complaint will be addressed. People staying at the home are protected from abuse. EVIDENCE: Four relatives returning surveys were aware of the home’s complaints procedure; two didn’t comment. One relative stated “Currently, I feel I could talk to staff about any concerns and that they would take on board my comments”. Other comments were received from relatives such as “staff are always available to discuss any issues” and a visiting relative said that were he to have a complaint he would speak to the manager “who addresses things immediately”. Information from the provider notes that four complaints had been received and responded to within the 28-day timescale. The complaints log could not be located during this visit, but the inspector was informed that these related to personal care needs and staffing. The complaint about staffing had been positively resolved and three were ongoing. A requirement is made, however, for the home’s complaints log to be available for inspection. Before someone is employed to work at the home, Criminal Record Bureau checks are carried out to ensure that they are safe to work with vulnerable Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 16 adults. Staff also receive training in adult protection to ensure that they understand what abuse is and how to report it. Notifiable incident reports received from the home indicate that where there has been an incident of potential abuse between people living at the home referrals are made to the local authority adult protection team and that, where appropriate, action has been taken to promote the safety of those living at the home. One visiting relative felt that her mother was “safe” at Castle Grange. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The environment at Castle Grange is safe and well-maintained, providing a clean, comfortable and pleasant environment for those living at and visiting the home. EVIDENCE: Castle Grange is a new, purpose-built care home providing a high standard of single, en-suite accommodation over two floors. A range of relevant equipment is provided to meet the diverse needs of people living there. Door locks are fitted to bedrooms doors, as are door alarms that alert staff should anyone, other than staff, open the door. Name plates are on bedroom doors to assist people in finding their room. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 18 Pictures and fresh flowers adorned the home giving it a warm and homely feel. The home was clean, tidy and odour free on the day of the visit. One relative returning a survey remarked that as far as keeping the home “clean and smelling fresh” staff “win with flying colours!” The home has a well-equipped laundry for the care of people’s personal clothing, and clothing looked well cared for. Bedding is sent to an external laundry. A relative returning a survey said she had been told when visiting the home that the laundry person would do any repairs that needed doing to clothing but that this was not happening. During this visit the inspector was informed that this is now happening. The same relative stated that clothing goes missing despite being labelled with names. Although the laundry appeared well organised during this visit, the home’s manager should take note of the comments about laundry and take any necessary action. The garden area provides a pleasant, secure, environment for people where they can sit and enjoy the outdoor environment. The garden was attractive with plants and shrubs, bird feeders, wind chimes and sensory equipment. A visiting relative said he was pleased with the sensory garden. On the day of the visit, the weather was dry and sunny and people were seen to move freely between the garden and the indoor area. A number of bedrooms were inspected, including those previously identified as having offensive odours. People’s bedrooms contained personal possessions to add to a homely feel and included specialist equipment where necessary to meet their needs. One person said that she had her “own room with lots of photographs”. Some bedrooms where the occupant has continence issues had non-slip floor coverings to promote good hygiene and a relative commented that the non-slip flooring in her relative’s room was easier to keep clean. None of the bedrooms seen had unpleasant odours. Good hygiene practice promotes people’s dignity and a previous requirement regarding the promotion of people’s dignity has been addressed. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 19 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The needs of people living at the home are met by the numbers and skill mix of staff. The home’s recruitment policy and practices ensure that people living at the home are supported and protected. EVIDENCE: Staffing arrangements are usually one carer on each suite with an additional carer who works between the first and ground floor suites. There are two team leaders, one on each floor on the morning shift and one team leader on the afternoon shift. A care co-ordinator and the manager are also on duty throughout the day, Monday to Friday, with an overlap between co-ordinators on the afternoon shift. One care co-ordinator is on duty throughout the day at weekends. During the night there are three wakeful night carers. A laundry assistant works five hours a day, Monday, Tuesday, Thursday, Friday. Personal laundry is washed at the home and bedding is sent to an external agency. Care and night staff attend to any outstanding laundry and provide laundry cover on Wednesdays and at weekends. Staff felt that for the majority of the time staffing levels were sufficient. Staffing arrangements have been reviewed so that on a morning, the manager Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 20 and co-ordinators serve breakfasts, thus freeing up domestic staff to concentrate on cleaning duties. And there have been clear improvements regarding hygiene at the home. However, staffing arrangements in the laundry should be reviewed so that laundry cover is provided over seven days as when care staff are attending to the laundry, they cannot also be available to people living at the home. (See Recommendations.) A relative returning a survey felt that the home could be improved by “employing more ‘shop floor’ staff, as sometimes the residents are left on their own”. From observation, staffing levels appeared sufficient with staff having time to sit with people. The home was busy, however, particularly over the time of the evening meal when the ‘floating’ member of staff had escorted someone to hospital. But a senior member of staff explained that she had been on the units and was ready to offer assistance to staff was this required. Staff working in the home were caring in their approach to people and demonstrated some of the skills necessary when providing care to people with dementia type illnesses. People living at the home were clearly comfortable and relaxed with the care staff and showed signs of positive well-being by smiling and presenting as calm and relaxed in their interactions with staff. People living at the home, relatives who spoke with the inspector and those returning surveys made positive comments about staff such as staff “are very, very good” and that they “do anything for you”. And “staff at all levels are friendly, helpful and aware of residents’ needs and safety”. During this visit a sample of three care staff recruitment records were audited and contained the required information, references and checks. Relevant training is provided to staff and 52 of staff have achieved an NVQ (National Vocational Qualification) at level 2 or above. New employees receive induction training in line with the Common Induction Standards when they first begin working at the home. And mandatory training in areas such as movement and handling, first aid, adult protection, food hygiene and health and safety is also provided. Future training in food hygiene, first aid and infection control has been planned. Training relevant to the client group, for example, person centred dementia is also provided. The majority of relatives returning surveys felt that staff had the right skills and experience to look after people properly; two felt they ‘usually’ had and one felt that this was reflective of agency rather than the permanent staff at the home. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. A person who is experienced and competent manages the home. Action is being taken to ensure the home is run in the best interest of people who live there. Arrangements are in place to ensure that people can access their monies, which are held in safekeeping. Generally, the health and safety of people living and working at the home is promoted and protected. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 22 EVIDENCE: At present Castle Grange is being managed by Anne Ashton. She is qualified and has many years’ experience of working with older people. Before moving to Castle Grange, Ms Ashton was registered with the Commission for Social Care Inspection. It was evident from surveys and discussion with relatives, that Ms Ashton is approachable and that she addresses any issues that are brought to her attention. In general, positive comments were received about the staff and management team at the home. As part of the home’s quality assurance process, surveys are sent to relatives and to people using the short-stay and long-stay facilities at the home, who are able to complete them. Whilst the information is yet to be fully collated, the vast majority of surveys seen during this visit made positive comments about the service. Senior management within the service also carry out monthly visits to the home and from reports received by the Commission it is evident that management seek the views of people using the service. Once complete a copy of the findings should be supplied to the Commission and made available to people using the service. (See Recommendations.) Monies are held in safekeeping on behalf of people living at the home, four of which were sampled during this visit. Clear records were being maintained and receipts available for any monies spent. Since the last inspection, arrangements have been made so that people can access their monies as they require. The home’s fire procedure was clearly displayed and an emergency plan included information and a photograph about individual’s living at the home should they need to be assisted in an emergency. The majority of staff have received fire safety training and staff spoken with confirmed this. Further training was arranged. Night care workers have yet to receive fire safety training, however, but the inspector was informed that this had been arranged for 03.05.07. The provider must confirm in writing to the Commission that all night staff have received fire safety training, including a fire drill, following the training on 03.05.07. A requirement is made about this. Equipment service records were sampled and show that relevant checks are carried out to ensure the health and safety of those living and working at the home. Records of accidents and incidents are maintained and where appropriate the Commission has been notified as required, therefore the previous requirement has been met. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 23 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 3 8 3 9 3 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 3 X X X X X X 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 X 3 X 3 X X 2 Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 24 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 OP16 Regulation 22 Requirement The home’s complaints log must be available for inspection when required. Timescale for action 30/05/07 2. OP38 23(4)(d) (e) All staff working at the care 03/05/07 home must receive fire safety training and be involved in a fire drill. (Timescale of 06.12.06 not fully met.) Following the training for night staff on 03.05.07 the registered provider must confirm to the Commission in writing that all night staff have received fire safety training, including a fire drill. 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 OP7 Good Practice Recommendations Statements within care plans such as “needs assistance”, “needs some foods cutting up” should be clearly explained DS0000067874.V336505.R01.S.doc Version 5.2 Page 25 Castle Grange 2 3 OP8 OP8 4 OP27 5 6 OP33 OP38 so that it is clear to anyone reading the document what form the assistance should take and which foods need cutting up. Where risks to a person receiving care have been identified these should be recorded on the risk assessment so that risk assessment documentation is fully completed Monitoring charts should be completed in a meaningful way, so, for example, where the amount of liquid or food is required to be noted, staff should record the amount rather than place a tick on the chart. Staffing arrangements in the laundry should be increased to cover seven days so that care staff are not taken away from their caring duties by having to attend to the laundry. Once available, a copy of the findings of the home’s quality survey should be provided to the Commission and made available to people living at the home. Action should be taken to assess the potential risk of service users entering kitchenette areas when hot surfaces are present during cooking. This was not checked and will be assessed at the next inspection. Castle Grange DS0000067874.V336505.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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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