Inspection on 10/08/05 for Castle Hall

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Hall 07/09/09

Castle Hall 15/08/07

Castle Hall 15/08/06

Castle Hall 06/12/05

Castle Hall 07/03/05

Castle Hall 18/08/04

Castle Hall 24/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Castle Hall 33 Lee Road Ravensthorpe Dewsbury WF13 3BE Lead Inspector Bronwynn Bennett Unannounced 10 August 2005 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Castle Hall Address 33 Lee Road Ravensthorpe Dewsbury WF13 3BE 01924 520270 01924 520270 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Huddersfield Mencap N/a Care Home 16 Category(ies) of Learning Disability - 16 places registration, with number of places Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 7 March 2005 Brief Description of the Service: Castle Hall is set in a residential area, in Ravensthorpe, Dewsbury, close to local amenities. The home is managed by Huddersfield Mencap, and is registered to provide personal care and accommodation for up to fifteen adults with a learning disability. Nursing care is not provided at this home. Accommodation is provided on two levels. The home is staffed twenty four hours a day. Waking night staff are provided in addition to a member of staff sleeping in on the premises. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting for a period of approximately seven and a half hours. The residents and the staff on duty were spoken to. The inspector also looked at written records. What the service does well: What has improved since the last inspection? 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 Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2. A record of the pre-admission assessment should be kept in the residents care records. EVIDENCE: There was no record of a pre-admission assessment being undertaken for one resident admitted into the home. A discussion took place with the manager about this. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9. All the residents have a care plan in place. Care needs to be taken to ensure that the detail and the language used in daily records are appropriate. EVIDENCE: The residents spoken with said that they feel supported by the staff and that the staff work hard. The care records for three residents were looked at. The details held in these care records is good. There was evidence that some residents had been involved and consulted about their plan of care. However one resident did not have any record of being consulted about their care plan and this was discussed with the manager. Some of the daily records were vague and an issue was raised with the manager about one of the entries. There was evidence in care records that the residents are assisted, by the staff in decision making. The staff support one resident to manage part of his own finances. The staff support the residents to access local independent advocacy groups. The manager informed the inspector that risk assessments are completed prior to, or shortly after admission to the care home. There were risk assessments in place for each resident in their care records. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17. The residents are provided with a varied diet and specialist diets are provided by the home. EVIDENCE: The inspector had lunch and the meal was well presented. The staff were seen to be appropriately supporting the residents throughout this inspection with food and drinks. Some of the residents said that they are consulted about the menus. Some residents choose to go out on occasions to the local pubs or restaurants for meals. The home offers a four weekly menu with a choice of food and specialist diets are catered for and currently provide low fat and blended diets. There are two refrigerators in the kitchen that are in need of repair or replacement. It was observed that the kitchen disposal bin is not the type that can be operated by foot control. To promote safe hygiene in the kitchen area a foot- operated bin should be provided. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20. Some of the residents are at risk of not having their healthcare needs met. The home’s policy and procedure for medication needs to be followed and greater care needs to be taken with the safe handling of medication. EVIDENCE: There were assessments in place for some resident’s health care needs. However, one resident did not have plan for wound care and skin care. One resident did not have a record of weight in place where the care records advise that the resident should be weighed monthly. There was a discussion with the manager about monitoring the weights of the residents. The organisation need to take action to ensure that the residents’ can be weighed as specified in their plan of care. There was a recording of the blood pressure for one resident that was not accurate. Such practices should be undertaken by the appropriate professional, or completed as part of the annual health checks. There are medication records kept for each resident. The medication records for three residents were looked at. The medication kept for one resident was out of date, there were signature omissions and the records for one medication could not reconciled with the records kept. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23. The residents feel able to raise any concerns or to make a complaint. EVIDENCE: There are monthly residents meetings carried out in the home to enable the residents to express their views or to raise any concerns. The home has a complaints procedure in place, however this policy requires updating to include the Commission for Social Care Inspection. There is a record kept by the home and the organisation of any complaints made to the home. The residents spoken with said that staff do listen to their views and that they would feel comfortable in raising concerns. The staff have a good understanding of adult protection issues but there was no whistle blowing policy available during this inspection. There is a procedure in place for dealing with residents’ money and financial affairs. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27,30. The home is generally clean and tidy but consideration should be given the services of a handyperson and a programme of maintenance. There is a lack of suitable hand washing facilities that pose a health and safety risk. EVIDENCE: The lounge and dining areas are clean, light and airy. The corridors are dark and are in need of suitable lighting and redecorating. The home does not have a planned maintenance programme, or the input of a handyperson on a regular basis. A discussion took place with the manager about the staff completing minor repair and maintenance works in the home. The bathrooms in the home are in need of updating, redecorating and repair. The identified shower room is in need of complete refurbishment. The broken tiles in this room are a potential health and safety risk to the residents. There was communal soap in the bathrooms. The use of communal soap should be discontinued in order to promote good hygiene and prevent cross infection. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 13 The laundry facilities were clean and well organised, but are in need of repair and redecorating. Both laundry rooms are fitted with washing machines that have sluicing facilities. There is a procedure in place for clinical waste and infection control. The home has a contract for water services and fittings. There were no hand washing facilities available in the laundry areas and this was discussed with the manager. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed during this inspection. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42. There is a potential risk to the health and safety of the residents’. The organisation must take action to resolve this. EVIDENCE: The manager was unclear as to who is responsible for the maintenance of the fire alarm system. This should be addressed as a matter of urgency to ensure the safety of the residents and the staff in the home. There is a fire procedure clearly displayed and fire alarm testing is completed on a weekly basis, as is the emergency lighting. Some of the staff have completed fire training and the staff spoken to during this inspection had a good understanding of the action to take in the event of a fire. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 1 Standard No 11 12 13 14 15 16 17 x x x x x x 2 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Castle Hall Score x 1 1 x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 17 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 19 Regulation 12(1)(a) Requirement Timescale for action 10.8.05 2. 3. 20 30 13.2 13.3 4. 42 23(4) (c ) The registered person shall promote and make proper provision for the health and welfare of the residents. The policy and procedure for 10.8.05 medication must be followed to protect the residents. There should be suitable 10.8.05 arrangements to prevent the spread of infection in the care home. A hand wash dispenser and paper towels should be made available in the laundry facilities The registered person shall make 10.9.05 arrangements for the maintenance of fire alarm system. The home should produce evidence of the maintenance schedule for the fire alarm. 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 Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 18 1. 2. 3. 2 6 17 4. 5. 6. 22 23 24 7. 27 The pre- admission assessment should be kept in the residents care records. The residents should be consulted about their plan of care. Where a resident has choosen not to sign their care plan this should be recorded. The refridgerators in the kitchen are in need of repair or replacement. To promote safe hygiene standards, the home should purchase a foot operated bin for the kitchen area. The complaints procedure should be updated to include the information for the Commission for Social Care Inspection. A whistle blowing policy should be made available. The home should consider appointing a handyperson to carry out repairs in the home. The home should develop a plan for the routine maintenance of the home. The identified bathroom and shower rooms are in need of refurbishments, repair and redecoration. Castle Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 19 Commission for Social Care Inspection Park View house Woodvale Office Park Woodvale Road Brighouse. HD6 4AB 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 Hall J51J01_s26340_Castle Hall_v243802_100805.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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