Inspection on 06/12/05 for Castle Hall

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 15/08/07

Castle Hall 15/08/06

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 Unannounced Inspection 6th December 2005 09:10 Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 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.V251246.R01.S.doc Version 5.0 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.V251246.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Castle Hall Address 33 Lee Road Ravensthorpe Dewbury West Yorkshire WF13 3BE 01924 520270 01924 520270 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 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.V251246.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person category LD/PD Date of last inspection 10th August 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. There are two waking night staff and an additional member of staff sleeping in on the premises. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by the inspector during a seven and a half hour period, and was the second inspection conducted during this inspection year. The inspector made a tour of the building and looked at a sample of the records kept by the home and spoke with some of the residents and staff. The inspection was conducted with help from the manager of the care home. What the service does well: What has improved since the last inspection? What they could do better: The care records must clearly identify the care required to meet the resident’s health and welfare needs. The organisation must address the general maintenance and refurbishment of the home. The organisation must take action to ensure the recruitment process is robust and sufficiently protects the residents. The organisation should develop a staff training and development programme to ensure that the staff are suitably trained to meet the needs of the residents. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 6 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 DS0000026340.V251246.R01.S.doc Version 5.0 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.V251246.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. There is no formal assessment process in place for potential residents. EVIDENCE: The manager has taken action since the last inspection and details of the peradmission assessment were evident on a residents care records. The organisation should consider the development of a policy and procedure for this activity to ensure a full assessment has been fully undertaken for each resident. There was no evidence in the care records kept that the registered person had confirmed in writing that having regard to the assessment the home is suitable to meet the needs of the resident. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection however; the inspector saw evidence in the records kept and through discussion with the manager that the residents are consulted about their plan of care. The manager is working hard to implement a person centred approach in the care planning process. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12,13,15,16. The residents are supported to be part of the local community and take part in appropriate activities. The residents are supported to maintain family links and friendships. Generally the residents’ rights are protected with the individuals’ choice and independence being promoted. EVIDENCE: There is a plan of care for all the residents regarding work and employment issues. There are no residents with jobs or educational training but the residents are supported to take part in community activity. The residents are supported to be part of the local community. The staff support the residents to go out to the local pub, cinema and places of interest. Some residents attend a local community day care, and a community worker visits the home and supports the residents to go out shopping and for walks. The residents are supported to maintain family and personal relationships. Family and friends are welcome to visit the home and the residents are supported to go out to visit friends and relatives. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 11 Generally the resident’s rights are respected. All the residents have access to their own key for bedrooms and a locked draw in their rooms. The manager said that the residents are free to choose preferred daily lifestyles. The residents’ choice of activity and preferred lifestyle is recorded in the care records kept for each resident. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 18,19,20. The residents do receive the personal support in the way they prefer but greater care to be taken to ensure the residents privacy and dignity is respected at all times. Generally the health care needs of the residents are met but some of the residents are at risk of their health care needs not been met. The homes policy and procedure for medication sufficiently protects the residents. EVIDENCE: The residents spoken with said that they are able to get up and go to bed when they choose to do so. The guidance and support that may be required by the resident is recorded in their care records. There is additional support available to the residents and a physiotherapist visits the home on a regular basis. The inspector did see a resident being assisted with personal care without due regard for their privacy and dignity and this was discussed with the manager. Where a resident needs support their privacy and dignity must be respected. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 13 A requirement was given at the last inspection in relation to the health care needs of the residents. The inspector did look at the health care needs in the care records kept for three residents and one resident did not have a care plan for wound care or skin care. It would be good practice to monitor the tissue viability for some of the residents and this was discussed with the manger. The medication for three residents was checked and all the medication could be reconciled with the records kept. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 14 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 the following standard(s): EVIDENCE: These standards were not assessed during this inspection but the home has updated the complaints procedure to include the details of how to contact the Commission for Social Care Inspection. The policy for whistle blowing was available for inspection. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 27,30. The bathrooms and shower rooms do not provide the residents with facilities that are adequate. There is a lack of suitable hand washing facilities that pose a potential health and safety risk. EVIDENCE: There was a recommendation made at the last inspection that the identified bathrooms and shower room used by the residents should be refurbished. The manager said that there are plans to complete this work later in the year, however the inspector feels that the organisation should now address this matter with some urgency to ensure that the residents are provided with suitable facilities. There are plans to change the laundry facilities in the home. The requirement given at the last inspection is carried forward until these changes are undertaken and there are suitable hand washing facilities made available to the staff. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Generally, a competent staff team supports the residents. The organisation should develop a staff training and development plan. The recruitment processes do not sufficiently protect the residents. EVIDENCE: There is currently two staff with NVQ level 2 and ten staff that are working towards achieving this qualification. The manager said that she supports the staff to provide the appropriate responses to the needs of the residents. The home has good links with other professionals to advise and educate the staff. There was no evidence on the day of this inspection that the organisation delivers structured induction or foundation training to the staff and this was discussed with the manager. Some of the staff have undertaken the LDAF (Learning Disability Award Framework) accredited training. The records for three staff working in the home were looked at. There were no original police checks kept in staff files and this was discussed with the manager. There were gaps in the employment histories for two staff and one of the records did not have suitable references. This is not acceptable and needs to be addressed. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39. The residents benefit form a competent manager who is fit to run the home. The home has a quality monitoring system in place that seeks the views of the residents. EVIDENCE: The manager was appointed at the home earlier this year and has achieved the NVQ level 4 award in management. Mrs Marlene Kenny must undertake her application to be registered with the Commission for Social Care Inspection. The residents spoken with advised the inspector that they are supported to express their views through ongoing consultation and residents meetings. The manager advised the inspector that the home does actively seek feedback from the residents and their relatives. The last quality assurance report was made available earlier this year. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 18 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 1 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 1 X X 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Castle Hall Score 1 1 3 X Standard No 37 38 39 40 41 42 43 Score 1 X 3 X X X X DS0000026340.V251246.R01.S.doc Version 5.0 Page 19 Yes 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 YA2 Regulation 14 (1) (b) Requirement The registered person must confirm in writing to the resident, that having regard to the assessment the care home is suitable for the purpose of meeting the residents’ needs in respect of their health and welfare. The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of the residents. The registered person shall promote and make proper provision for the health and welfare of the residents. Previous timescale of 10/08/05 not met. The registered person shall having regard for the care home and the needs of the residents ensure that the care home is kept in a good state of repair internally and externally. That all parts of the care home are kept clean and reasonably decorated. There should be suitable arrangements to prevent the DS0000026340.V251246.R01.S.doc Timescale for action 06/01/06 2. YA18 12 (4) (a) 06/01/06 3. YA19 12(1)(a) 06/02/06 4. YA27 23 (2) (b) (d) 06/03/06 5. YA30 13.3 06/03/06 Castle Hall Version 5.0 Page 20 6. YA34 19(1)a,b, (I) 7. YA37 8 spread of infection in the care home. A hand wash dispenser and paper towels should be made available in the laundry facilities. Previous timescale not met 10/08/05 (Regs 19(1)a,b, (I)para 1–9 of sch 2, c.) The registered person shall not employ a person to work at the care home unless, the person is fit to work in the care home and, they have obtained in respect of that person the information as specified in the requirements opposite. The registered person must ensure that there is a proposed registered manager application to the Commission for Social Care Inspection. 06/01/06 06/01/06 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. 2. Refer to Standard YA32 YA35 Good Practice Recommendations The staff working in the home should continue working towards NVQ level 2 in care. The organisation should develop a staff training and development programme to ensure the staff are appropriately trained to meet the needs of the residents. Castle Hall DS0000026340.V251246.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office 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 DS0000026340.V251246.R01.S.doc Version 5.0 Page 22 - 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. 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