Inspection on 06/06/06 for Castle Grange

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 01/05/07

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 Unannounced Inspection 11:00 6th June 2006 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.V288384.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.V288384.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 Mrs Jenny May Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 31 Nursing and 8 Personal Care in an overall total of 39 for older people One named person under 65 years of age may be accommodated. Date of last inspection 26th January 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 June 2006 are Nursing £401per week Personal care £307 per week Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection took place on 6th June 2006 and took place over six hours and was a key inspection. Discussions were held with the service users about their experience of living at Castle Grange. Fourteen service users surveys were sent to the home prior to the inspection seven were returned. The views of health and social care professional 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, menus various dietary charts service users 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 Registered Nurses care staff cook and domestic staff about the management and daily working practices of the home. What the service does well: The majority of service users spoken to or surveyed were “happy with the care at the home” They confirmed that staff treated them with dignity and respect and that generally the “care and support provided was very good” Service users said the food had improved. Service users approved of the two sittings at mealtimes which have been recently, saying that the dining room was less noisy and meal times felt like a more social occasion. The staff are working as a cohesive team to ensure that the service users receive a good standard of care. Staff are aware of the care and support needs of the service users and positive and interactive relationships were observed between service users and staff. 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. Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 6 The standard of décor at Castle Grange remains good and provides a comfortable and pleasant environment for service users to live. Southern Cross Healthcare have robust systems policies and procedures which ensure that service users are well cared for and protected from abuse. What has improved since the last inspection? There have been significant improvements at the home since the last inspection which include. Southern Cross Healthcare who own the home have had all their policies and procedures approved by the Commission for Social Care Inspection these are now implemented and form the basis ensure that the home provides a good standard of care and that the home is managed in an efficient and effective way which protects the health safety and welfare of service users and staff. Service users and relatives said that the care at the home had improved. The staff morale has improved and staff have had access to ongoing mandatory and specialist training opportunities and regular supervision. The standard of cleanliness at the home has improved with furnishings being washed or cleaned. Some bedrooms have had new carpet laid The dining room has been redecorated and the introduction of the two sittings at mealtimes is welcomed by service users who “said the mealtimes were more sociable” An acting manager has been appointed and service users and relatives said she was “approachable and kind” Health and social care professional commented that they had seen improvements in the home since her appointment Southern Cross Healthcare have implemented a robust recruitment and selection policy and procedure which protects service users. Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 7 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. Castle Grange DS0000025093.V288384.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.V288384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 3 4 and 5 The quality of this outcome is good this judgement has been made using available evidence including a visit to the service. The homes Statement of Purpose and Service User Guide are well written and detailed providing service users and prospective service users and /or their relatives with details of the service the home provides enabling an informed decision about admission to the home. The homes pre admission assessment document is comprehensive ensuring that service users needs prior to admission will be fully assessed. Issues of equality and diversity need to be explicitly addressed and recorded as part of the pre admission documentation which will ensure that the all the needs of service users are appropriately met. Intermediate care is not provided at Castle Grange. EVIDENCE: Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 10 Since the last inspection the Statement of Purpose and Service User Guide have been reviewed and approved by the Provider relationship Manager for the Commission for Social Care Inspection (C.S.C.I) Both the statement of Purpose and Service User Guide have been published for Castle Grange and a folder is available which includes both documents together with a copy of Southern Cross Healthcare Mission statement and a business card with Castle Grange managers name on it. These folders are given to potential service users when a pre admission assessment is completed by the manager. There are also copies of the service users guide left in each of the service users bedrooms. All potential service users and/or their relatives are encouraged to visit the home prior to admission. The acting manager confirmed that they can stay for varying lengths of time to meet their individual needs. On the day of inspection one service user spoken to had been unable to visit the home due to their frailty. There family had been encouraged and supported by the staff at the home to take photographs so that the service user had some insight into the environment of the home and what their bedroom was like. The service user said “This had helped me to make my mind up to move in “ Social care professionals spoken to as part of the inspection process confirmed that potential service users were able to visit the home prior to making a decision to move into the home on a permanent basis. Southern Cross has introduced comprehensive and detailed service user documentation which includes the pre admission assessment document. Minor adjustment to this documentation would ensure that issues of equality and diversity are explicitly addressed as an integral part of the pre assessment process. 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. No intermediate care is provided by the home. Castle Grange DS0000025093.V288384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11. The quality in this outcome area is adequate this judgement has been made using available evidence including a visit to the service. Care plans, risk assessments, daily health records for each service user are up to date and reviewed monthly by the qualified nurses at the home. This ensures that the current and changing care needs of the service users are identified, service users said that the care had improved but raised issues that need further attention so that all needs are met. Service users feel they are always treated with dignity and respect and their right to privacy is recognised and respected by the staff group. Equality and diversity issues need to be explicitly addressed and recorded throughout the care planning process so that the individual needs of all service users are met. EVIDENCE: All service users in the home have an individual care plan, which is formulated on admission to the home, reviewed by the qualified nurses on a monthly Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 12 basis. Daily health records are recorded daily for each service user this includes any critical incidences plus any visits from GPs, specialist nurses etc. The acting manager was able to give examples of how equality and diversity needs would be met, however not all issues are explicitly recorded as part of the care planning process. The current documentation does not contain a section that would identify equality and diversity issues automatically, the documentation needs to be reviewed and a section provided to ensure that equality and diversity needs are addressed This care plan is very detailed and contains the relevant information as to how the individual and changing needs of service users are to be met. Discussion with service users and their relatives spoken to as part of the inspection said that they were provided with the care and support they needed and that the “staff were kind and caring” All service users 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. Questionaires distributed to service users health and social care professionals as part of the inspection process identified that although the majority were very happy with the care they received. There were some issues which need to be addressed these include service users commented that on occasions “ there needed to be a faster response” by the staff when service users needed assistance to use the toilet. Another service users said that night medication was some times given out late, which meant that they were tired and unable to go to bed or that when they went to bed staff would wake them up to administer medication. Discussion with the acting manager said she would review and investigate the issues raised. Another service user said that they were not “given a drink in the evening”, although the inspector was informed that supper of tea and toast or biscuits is served at 7pm and another drink is provided later by night staff. During the inspection the majority of service users confirmed that they receive refreshments in the evening. A service user who was being nursed in bed said they were comfortable and that the staff “popped in “ during the day for a “chat”. The room temperature was comfortable and all personal items were within easy reach of the service user and the bedding which the service user said “was changed daily” was clean and fresh. The service user who needed a soft diet had a copy of the daily menu to select their meal choice, which was nicely presented. No service user at the home self medicates, all medications for service users are administered by the nurses in the home. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). All service users in the home are supported by staff to receive their NHS entitlements these visits are recorded in the care plan. Service users and Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 13 healthcare professionals surveyed confirmed that any visits were conducted in the privacy of the service users bedrooms and that if the service users wished to speak to the G.P. in private this was facilitated by the staff group. Surveys completed by health and social care professionals who visit the home all commented that the standard of care provided at the home is good and that the home works in partnership with them Numerous thank you cards acknowledging the care provided were displayed on the notice board. Castle Grange DS0000025093.V288384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15. The quality in this outcome area is good this judgement has been made using available evidence including a visit to the service. Service Users have choice and flexibility how they spend their day in the home, and pursue leisure activities according to their choice and preferences. This allows independence and individuality for each service user. The provision of meals in this home offers variety, choice and caters for individual dietary needs which helps to maintain the service users health and wellbeing. EVIDENCE: Service Users confirmed that they are able to choose how they spend their days and said that they were able to “spend time alone in their rooms or in the communal parts of the home” Relatives and visitors are encouraged and made welcome when they visit the home and are able to see service users in the privacy of their own room or in the communal areas. Castle Grange has an Activities Coordinator who works 10 hours per week she coordinates the activities at the home, asks service users about their preferred Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 15 interests and hobbies and develops an activity programme which includes a range of activities the activity programme is displayed on the notice board. During the inspection service users and staff were involved in a craft session on the patio which service users said they enjoyed. The home makes an effort to mark 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. Photographs of these occasions were displayed on the notice boards at the home. The home is affiliated to Everton Football Club and photographs showed service users enjoying an afternoon out at the club with a game of table football. A recent service user and relatives meeting had an agenda item that asked for suggestions for other activities the service users would like to be held at the home. A questionnaire returned to C.S.C.I suggested that there should be more activities specifically targeted towards the minority group of male service users this is an issue that should be considered. Ministers of religion visit the home and conduct services for the service users. The dining room has been redecorated since the last inspection new table linen was on the tables during the inspection. This makes the dining room brighter and homely. Menus were available on the tables. 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 improved. 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 service users, unless contraindicated for health reasons are offered a glass of sherry at lunchtime. Service users 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 “service users said they enjoyed their food” other service users 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 Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 16 The acting manager has introduced charts which identify the daily food intake of all service users and a food audit that tests the service users satisfaction at every meal. The chart should include suppers and refreshments served. Castle Grange DS0000025093.V288384.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. 17.18. The quality in this outcome area is good this judgement has been made using available evidence including a visit to the service. The home has clear policies and procedures for dealing with complaints and adult protection issues which ensures the users are protected from abuse. Financial accounting systems are in place which protect service users from the risk of financial abuse EVIDENCE: Since the last inspection the Provider Relationship Manager for C.S.C.I has approved Southern Cross Healthcare complaints and adult protection policy. The complaints procedure is included in the service users guide and is available for No internal complaints have been received since the last inspection. The home has a robust complaints procedure, which is documented in the service users guide and displayed in the hall on the notice board for service users and visitors to see. Service users surveyed said they knew whom to speak if they had any complaints. Those interviewed during the inspection said they were sure that any issues raised would be dealt with. Service users said that the staff at the home are “kind and caring” A newly admitted service user Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 18 said they knew about the complaints procedure and would speak to the manager if they wanted to make a complaint they were confident that their concerns would be addressed. The care home has up to date information on the Protection of Vulnerable adults, this information is communicated to new employees at their induction course. The pre inspection questionnaire received by C.S.C.I. identified that adult protection training had been delivered since the last inspection. The acting manager confirmed that all staff in the home had completed training on protecting vulnerable adults. Those staff spoken to said that the regional manager had delivered adult protection training and demonstrated their knowledge of adult protection issues and the impact on their practice. Staff stated that they would have no hesitation in raising any issues with the manager or senior manager if the issue was not addressed. Service users who can manage their personal finance are encouraged to do so. Any money managed on behalf of the service users is recorded signed and audited. Since the last inspection service users accounts have been reconciled. On the day of the inspection all service user accounts were banked appropriately with no evidence of any service user subsidising another service users expenditure this is an improvement on previous inspections. Castle Grange DS0000025093.V288384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.2425.26. The quality in this outcome area is good this judgement has been made using available evidence including a visit to the 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 service users to live. EVIDENCE: There is a programme of ongoing maintenance at the home which the handy man undertakes. The lounges were warm comfortable and clean. The dining room which has been redecorated since the last inspection was pleasant. Tables were set with crockery and cutlery fresh laundered tablecloths and a menu on each table. A tour of the building confirmed the standard of hygiene has improved significantly since the last inspection. Curtains in the service users bedrooms Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 20 and corridors had been laundered and were looking and smelling fresh and clean. The acting manager confirmed that there is now a rota in place to ensure that furnishings are washed and cleaned on a regular basis. 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. In one bathroom there was a dirty commode pan left in the bath which would contribute to cross infection. This was also observed during the last inspection. The acting manager took steps to check who had placed the commode in the bath all staff on duty denied it was any of them. The acting manager said she would attempt to identify who was doing this and ensure that this practice is stopped. There are a range of aids and adaptations available at the home to meet service users assessed needs. Castle Grange DS0000025093.V288384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30. The quality in this outcome area is good this judgement has been made using available evidence including a visit to the service. The recruitment practice and policies are robust ensuring the protection of service users. Staff morale has improved resulting in an enthusiastic workforce who have a good understanding of service users health and care needs. The staff are working positively with service users to improve their whole quality of life. 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 a first level Registered Nurse on duty who is assisted by 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 and commented that since the last inspection they had access to increased training opportunities. Staff said they “felt included and involved in the running of the home ideas and suggestions were listened to” Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 22 Discussions and surveys from service users and relatives said “staff were kind and caring” and that staff responded , listened and acted on what they said. A newly admitted service user nursed in bed said that “staff pop in during the day for a chat and to ask if I need anything” and commented that this stopped them feeling isolated. There were a couple of concerns raised in the surveys around the response time for toileting needs and lateness of night medication. These issues were discussed with the manager who agreed to investigate review and change practice. Overall the surveys and discussions with service users and relatives said that “Care and support given is very good” One relative commented that the “home has improved in recent months and the staff are welcoming and friendly when you visit” Since the last inspection there has been an increase in the mandatory and specialist training provided to staff. All staff since the last inspection have had access to Adult protection training which was delivered by the regional manager of Southern Cross. The acting manager has delivered two sessions on the control of infection to the staff group. Further mandatory training is planned. Records are kept of all training attended by staff. Staff spoken to who had attended an “in house “course “Eat well eat safe nutrition” commented how beneficial the course had been and gave examples how they had implemented issues raised during the course into practice. Six staff are currently registered on the N.V.Q level 2 award. Three staff currently hold N.V.Q Level 2 and one has N.V.Q Level 3. Southern Cross have implemented a robust recruitment and selection policy which protects service users. Personnel files reviewed showed that all the documentation required in Schedule 2 of the Care Standards Act 2000 was available for inspection .The organisation has a comprehensive equal opportunities policy relating to staff management. The staff group at the home reflect the make up of the wider community in gender, age and racial diversity. Castle Grange DS0000025093.V288384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.32.33.34.35.36.37.38. The quality in this outcome area is good this judgement has been made using available evidence including a visit to the service. The acting manager is well supported by the qualified nurses in providing clear leadership at the home which ensures that service users are provided with a good standard of care. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. Service users financial interests are safeguarded and protected by the recording and financial auditing systems which have been implemented at the home The health safety and welfare of service users and staff are safeguarded by the regular safety checks conducted at the home. Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Acting Manager is a Registered General Nurse with many years experience working with the service user group. The acting manager is working towards N.V.Q Level 4 in Generic management 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 the atmosphere at the home was more positive. “ Care standards have improved” and the manager is “approachable and friendly”. Following her probation period with Southern Cross she will apply to C.S.C.I to become registered. The acting manager provides leadership and direction at the home supported by the qualified nurses. Social and healthcare professionals said that she was a “positive influence” The manager was keen to say that “the improvements at the home have been a team approach with all staff at the home playing a part in the improvements.” The staff morale at the home has improved and staff “said they felt involved and included”. Service users and relatives knew who the manager was by name and a relative confirmed they had received a letter of introduction when she had taken up her post. Relatives confirmed they had been invited to attend a service user/ relatives meeting minutes were seen of the meeting. Since the last inspection the staff group have been able to develop new skills and the training opportunities for staff have increased. Staff are regular supervision which is recorded. A Staff meeting has been held minutes are kept. Service users, staff and health and social care professionals spoken to as part of this inspection all commented on the “positive influence and management style” of the acting manager and said the home had improved under her leadership. Service users said that they were” happy” in the home and that the manager was “lovely and kind” and they had the chance to talk to her each day she was on duty. During the inspection the issues of diversity and equality were discussed at length with the acting manager who was able to give explanation and examples of how the needs of service users from a variety of cultures would be met in relation to diet religious observances and personal care. The acting manager said she would make enquiries from homes in Southern Cross Healthcare to obtain additional information and increase her knowledge. Ten days following the inspection a copy of “Multicultural Nursing a cultural and Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 25 spiritual awareness” published by the Royal College of Nursing was sent to the C.S.C.I. The manager has been able to share the publication with staff working towards their N.V.Q. Level 2 Award which as helped them increase their awareness of equality and diversity issues. Service users who can manage their personal finance are encouraged to do so. Any money managed on behalf of the service users is recorded signed and audited. Since the last inspection service users accounts have been reconciled. On the day of the inspection all service user accounts were banked appropriately with no evidence of any service user subsidising another service users expenditure this is an improvement on previous inspections. 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 Regulation 26 visits copies of which have been forwarded to 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 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.V288384.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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 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 2 3 3 3 3 3 3 3 Castle Grange DS0000025093.V288384.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. 1 Standard OP3 Regulation 14 Requirement The registered person is required to ensure that issues of equality and diversity are explicitly addressed in the assessment process. The registered person is required to ensure that issues of equality and diversity are explicitly addressed in the care planning process. The Registered Provider shall appoint a person to manage the care home who has the qualifications skills and experience necessary for managing the care home. The newly appointed Acting manager must apply to become registered following her probationary period. This requirement is outstanding from previous inspection report. Timescale for action 01/08/06 2 OP7 15 01/08/06 3. OP31 8 01/10/06 Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 28 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.V288384.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Castle Grange DS0000025093.V288384.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!