Inspection on 15/08/07 for Castle Hall

This inspection was carried out on 15th August 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Castle Hall 07/09/09

Castle Hall 15/08/06

Castle Hall 06/12/05

Castle Hall 10/08/05

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 Dewbury West Yorkshire WF13 3BE Lead Inspector Bronwynn Bennett Key Unannounced Inspection 15th August 2007 09:50 Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 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 Hall DS0000026340.V341569.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 Adults 18-65. 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 Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Hall Address 33 Lee Road Ravensthorpe Dewbury West Yorkshire WF13 3BE 01924 520270 NONE None 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) Huddersfield Mencap Mrs Marlene Kenny Care Home 16 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (16) of places Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person category LD/PD Date of last inspection 15th August 2006 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. There are two waking night staff and an additional member of staff sleeping in on the premises. The provider informed the Commission for Social Care Inspection on 12.6.06 that the fees range from £518.00 to £633.00. There are additional charges for hairdressing, newspapers and magazines, toiletries, trips and holidays. Information about the home and the services provided are available from the home in the statement of purpose and the service user guide. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit. The visit began at 9.50am and finished at 4.40 pm. During this visit the inspector spoke to people living at Castle Hall, some staff and the manager. The inspector read records of people’s care and staff records, looked at how medicines are given and looked at the accommodation available in the home. There were sixteen people living at the home on the day of this visit. Before this visit the Commission for Social Care Inspection sent out questionnaires. Eleven questionnaires were sent to people living at the home and everyone responded. Six questionnaires were received from relatives and five healthcare professionals. Prior to this visit the manager gave the CSCI information that had been requested, for example about any illnesses, accidents and incidents and how the home is managed. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: People live in a homely environment and are supported by a caring staff team. There were many positive comments made in the surveys received by the CSCI for example ”Staff are always helpful and welcoming” and a healthcare professional said, “Staff at Castle Hall are exceptional. We can’t fault the care observed” People spoken with during this visit said the staff are supportive and they were happy living at the home. The care records are person centred and people are involved in their plan of care. People are supported to make decisions in their lives and staff supports them in their chosen lifestyle Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No individual moves in to the care home without having their care needs assessed. EVIDENCE: The admission procedure for admitting new people into the home was discussed with the manager. Social services assessments and care plans were seen in the records looked at. No person moves in to the care home before their care needs have been assessed. In addition, short visits are encouraged so that people can meet others living in the home. As part of the survey people were asked if they received enough information about the home before deciding to live there, everyone responded, “Yes”. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual assessed, personal goals and needs are reflected in their plan of care. People make decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: Overall everyone who responded to the relatives survey felt the needs of their loved one are met by the care home. One person commented they “are always consulted”. Generally, relative’s comments from the survey were positive when asked if they are kept up to date regarding important issues affecting their relative. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 10 Individuals spoken to during this visit said they were happy living at the home. During this visit people were observed being supported by the staff in a caring manner. The comments received from people living at Castle Hall indicate that people can make decisions about what they do each day. Three care records were looked at during this visit. The content of these files continues to be good. Care plans are person centred and individuals are involved in their ongoing plan of care. People spoken to during this visit said they had a care plan and knew their key worker. The care records looked at, showed evidence of ongoing consultation with the individual and were reviewed and up to date. The reviewing of care records was generally detailed and person centred and showed whether or not the care plan is working. This is good practice and should continue. Risk assessments were in place for each individual that support people to take risks as part of their chosen lifestyle. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to be part of the local community and take part in appropriate activities. Individuals’ are supported to maintain relationships with family and friends and the rights of people are respected with their choice and independence being promoted. EVIDENCE: There is no one currently living at Castle Hall undertaking paid employment or educational training. People are supported to be part of the local community. Some people choose to go out independently and some individuals require some support from the staff. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 12 Everyone continues to have access to local facilities such as shops, chemist, pubs, clubs and places of interest. On the day of this visit people were being supported by staff to enjoy their chosen activity. The home has worked hard to provide people with stimulating and enjoyable activity. Currently the staff are active in organising “Themed Nights” that people can take part in. Personal relationships with family and friends are supported and encouraged. One person said they are able to have visitors when they wish. There are facilities at the home for family and friends to meet one another in private. Respecting privacy and dignity is recorded in individual care plans and care records. People are offered a key to they room and provided with lockable facilities for keeping their belongings private and safe. Where people have chosen to carry out domestic duties such as cleaning their room this is recorded in the care record. Everyone spoken to during this visit said the staff team supports them well. During this visit people were being supported in a respectful and dignified manner by the staff. Everyone spoken to said the food was good and there is plenty to eat. The inspector sampled a meal that was well presented and enjoyable. An alternative menu offered looked appetising. People were given the appropriate support where required to enjoy their meal. The home offers a choice of main meal and a three weekly menu is provided. The cook has developed detailed nutritional plan for everyone that informs staff of individual dietary choices and dietary needs. The local council has awarded the home a healthy eating award. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support in the way they prefer and their health care needs are being met. The medication policies and procedures sufficiently protect people living at the home. EVIDENCE: A positive response was received from individuals who were asked as part of the survey if the staff listen and act on what they say. A healthcare professional said that individual privacy and dignity is respected. People spoken to during this visit said the staff were helpful. One person said, “Staff are very good” Individual health care records were seen in the care records looked at. People are supported to access NHS appointments and facilities and a physiotherapist visits individuals living in the home. People have their weight monitored on a monthly basis. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 14 There are risk assessments to measure the risk of developing pressure sores (Waterlow risk assessment) Where a risk assessment identifies a person is at risk of developing a pressure sore, there must be guidance for staff to inform them of the actions they must take. This was discussed with the manager who agreed to take action in the matter. The medication and medication records checked for three people were correct. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home, their relatives and advocates are confident their views are listened to and acted upon. People are protected from abuse. EVIDENCE: The home has a complaints policy and procedure in place and displayed in the home. Everyone who responded to the survey said they knew who to speak to if they were not happy and nine out of ten individuals living at the home knew how to make a complaint. People spoken to during this visit said they would tell someone if they had any concerns or were unhappy about something. There have been no complaints made to the home since the last visit by the CSCI. The home has a policy and procedure displayed in a suitable format for people living at Castle Hall. The financial records and money for three people checked was correct. The staff spoken to during this visit had a good understanding of the actions that must be taken should there be any allegations of abuse. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 16 The manager confirmed that all the staff have undertaken safeguarding (adult protection) training. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean, hygienic and generally well maintained. EVIDENCE: The surveys from everyone living at the home said the home was always fresh and clean. A relative said their loved one has a “nice newly decorated room” another said, “the room is spotless, there are never any smells”. On the day of this visit the home was clean and generally odour free. The home provides a homely and relaxed environment for people. There have been many improvements made to the home since the last visit by the CSCI. The hallways and corridors have been repainted and additional lighting has been installed and provides a pleasant environment for people. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 18 However, the bathrooms on the first floor require some refurbishment. The manager said that there is ongoing maintenance work planned in the home. Communal areas of the home have been redecorated and fitted with replacement blinds and curtains. One lounge is a designated smoking area, and although fitted with an extractor fan, it does not sufficiently remove the odour of smoke. It is a recommendation of this report that suitable extraction is fitted to this area. One bathroom has undergone some major refurbishment and provides people with suitable showering facilities. The laundry area was clean and well organised. The manager advised that this area would be repainted as part of the homes programme of maintenance. Some individual rooms seen had been personalised with a personal choice of bedding, furniture, pictures and personal effects. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 19 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall a competent staff team supports people living at the home. People are protected by the organisations recruitment policy and procedure. EVIDENCE: The response to the surveys was positive when people were asked if the staff treats them well. A healthcare professional commented that the staff always ensure individual privacy and dignity is respected. Two relatives responded “ We are happy with the care given”. “The staff are all very caring and do a good job”. 41 of the care staff has achieved NVQ (National Vocational Qualification) level 2 in care. This training should continue for staff. All new staff receive induction training. The staff records showed that staff have completed mandatory training such as safe movement and handling, Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 20 safeguarding (Adult Protection), infection control, or this training is planned. Some concerns were raised during this visit regarding specific areas of knowledge required by the staff. See Standard 42. The manager has worked hard to provide training to ensure staff are appropriately trained. The recruitment records looked at for three staff contained the required information and police checks. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a home that is well run and operates in their best interests. The health, safety and welfare of everyone is generally promoted and protected. However, the organisation should ensure that safe movement and handling training meets the needs of the service. EVIDENCE: The manager is Mrs Marlene Kenny. She is registered with the CSCI. And since the last visit by the CSCI she has achieved NVQ Level 4. The home is run in the best interests of people. Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 22 The staff and the people spoken to during this visit made positive comments about the manager for example, that she is approachable and supportive. There is a quality monitoring system in place. Monthly management review reports and quality audits are completed by the home. Questionnaires in suitable formats are sent to people living at Castle Hall and the results of consumer surveys are made available in the home. One health care professional responded to the survey and said “Staff at Castle Hall are exceptional. We can’t fault care delivery observed. The environment is clean and homely. Always a relaxed atmosphere. Residents always appear happy”. There are staff and residents’ meetings so that everyone can express their views and contribute to how the home is run. The response from the survey was positive when people were asked if staff listen and act on what they say. The fire records and a sample of maintenance records examined were up to date. This promotes the safety of people living in the home. Mandatory training of staff such as safe movement and handling, infection control and safeguarding (Adult Protection) has either being completed by the staff or the training is planned. There was some concern during this visit regarding some staff not being suitable trained in the use of specialist moving equipment such as a hoist. The organisation has taken immediate action to address the matter. No staff will use the hoist until they have received this training. Castle Hall DS0000026340.V341569.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 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 X Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13.5 Requirement All staff must undertake manual handling training that includes the use of equipment such as a hoist before moving people in the home. Timescale for action 15/10/07 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 YA19 Good Practice Recommendations More detailed information is required in the individual pressure care risk assessments (Waterlow) to ensure the staff have the correct information about the actions they must take. Extraction facilities in the smoking area require improvement to provide a comfortable environment and ensure odours from smoke are controlled. Staff should continue working towards achieving NVQ (National Vocational Qualification) level 2 or above in care. 2. YA24 3. YA32 Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Castle Hall DS0000026340.V341569.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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