Inspection on 05/03/07 for Castle Hill House Limited

This inspection was carried out on 5th March 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Castle Hill House Limited 09/02/09

Castle Hill House Limited 15/06/06

Castle Hill House Limited 09/02/06

Castle Hill House Limited 12/10/05

Castle Hill House Limited 23/03/05

Castle Hill House Limited 07/09/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Castle Hill House Limited Castle Hill House Castle Hill Bodmin Cornwall PL31 2DY Lead Inspector Kerensa Livingstone Key Unannounced Inspection 5th March 2007 09:30 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 Hill House Limited DS0000054294.V318059.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 Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Hill House Limited Address Castle Hill House Castle Hill Bodmin Cornwall PL31 2DY 01208 73802 01208 75836 castlehillhouse@hotmail.com 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) Castle Hill House Limited Care Home 20 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (20), Physical disability over 65 years of age (20) Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 20 adults of old age (OP) Service users to include up to 20 adults aged over 65 with a physical disability (PD{E}) Service users to include up to 4 adults, aged over 65 with dementia (DE{E}) Service users to include up to 4 adults aged over 65 with a mental illness (MD{E}) Total number of service users not to exceed a maximum of 20 Date of last inspection 15th June 2006 Brief Description of the Service: Castle Hill House is a care home registered to provide nursing care for up to twenty Service Users over the age of sixty-five. Four of the beds in the home are registered for service users with a dementia DE (E) and four beds are registered for service users who have a mental disorder MD (E). Since the last inspection new owners have purchased Castle Hill House and a new Manager appointed. The ethos and management of the home has changed significantly. The front door to the home had been locked and access gained by ringing a bell. This has changed and the door is now unlocked to allow visitors to enter the building freely. Considerable reinvestment is planned into the home and new facilities are to be provided. The home is a grand older style residence set in it’s own grounds in a quiet residential area on the outskirts of Bodmin. The home is in an elevated position, providing super views over the surrounding countryside. There is a large car park to the side of the home. Bedrooms are situated on the ground and first floor. There is a shaft lift that can take a wheelchair. There is a lounge and dining room on the ground floor. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted over a full day by one inspector who knows the home. The inspection lasted over eight hours. The inspector spoke with the Manager and Registered person, staff and Service Users. The environment was inspected and documentation relating to all aspects of the service scrutinised. Casetracking and formal observation of a mealtime were used. Pre inspection information including questionnaires from service users and their relatives were submitted prior to this inspection. It was evident that a considerable amount of work had been undertaken since the last inspection. The ethos of the home is clearly to establish systems that are driven by the wish to provide a high standard of individualised care for the service users. The Manager has been in post for four months and the new owners for seven months, a significant amount has been achieved and the momentum to continue these improvements was evident. The current fees are £444.25 - £470 What the service does well: What has improved since the last inspection? There is clear evidence that service user’s health and personal care needs are being met, there is a significant improvement in the recording systems and a lot of hard work is evident. The managerial and administrative systems are improving significantly to meet the needs of the service users and to support the staff delivering the care. The ethos of the home is clearly to establish systems, which are driven by the wish to provide a high standard of individualised care. The Manager has been in post for four months and the new owners for seven months, a significant Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 6 amount has been achieved and the momentum to continue these improvements was evident. The staff are being provided with the skills and knowledge that they require to meet the service user’s needs. Induction, fire training, moving and handling and health and safety is being provided initially. Staff are being offered National Vocational Qualification level 2 and 3 training. There is a robust recruitment and selection process to ensure the Service Users are protected and their needs are met, in an individual and collective way. Service users value the staff and speak highly of them. Activities are being developed to ensure that they meet the needs of the service users, an activity coordinator is due to commence working 3 days a week at the home. Supervision and appraisals for staff is being commenced. 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 Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 7 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 Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to moving into the home to ensure that they can meet their needs and that it meets the needs of the service user. The Statement of Purpose and the Service user’s guide are currently being compiled; this will provide clear information for prospective and current service users. All service users must have contract of terms and conditions with the home. EVIDENCE: A new Statement of Purpose and Service User’s Guide is currently being compiled. The Registered person and inspector discussed the importance of these key documents. The Service user’s Guide must be provided to all prospective and current service users on its completion. It must include the information detailed in Regulation 5 such as the most recent inspection report, Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 9 contract, and fees. It is recommended that it includes service user’s views of the home. New service users to the home are being provided with a contract including their terms and conditions, this includes the required information such as the number of the room that they have been offered. The registered person and inspector discussed the importance of ensuring that all service users have signed a contract. One longer standing service user had an unsigned contract in their file. The registered person agreed that this would be checked and remedied if need be. New Service Users are admitted following a full assessment incorporating the required information by a qualified nurse. Service users informed the inspector that they had met the Manager prior to coming to live at Castle Hill House to discuss their needs. The Inspector observed that families or their representatives and other professionals were involved in this thorough process. A plan of care is based upon this needs assessment. Intermediate care is not provided in this home; there is no designated equipment or staff for this. Therefore this standard is not applicable. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear evidence that service user’s health and personal care needs are being met, there is a significant improvement in the recording systems and a lot of hard work is evident. Medicines were observed to be administered safely, Policies and Procedures are required. Service users feel that they have the privacy that they would like. EVIDENCE: The pre admission assessment forms the basis for planning the care. A new system is being introduced, so there were two different systems running at the time of the inspection. Each service user has a care plan, which includes all aspects of care and details the action needed to ensure that the service user’s needs are met. There are plans to develop the social aspects of the care planning. There is evidence of Service User and/or family involvement. Service users are offered the opportunity to consider and contribute to their plan of care. These are reviewed monthly. Each Service Users has a keyworker and a daily record is kept. A handover sheet is used to promote good communication. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 11 The inspector was impressed with the quality and level of detail included in the new care plans. A handover sheet has been introduced to improve continuity of care. All Service Users are registered with a General Practitioner. The home reports good working relationships with the local Primary health care team. Assessment tools are used within the home, for example a nutritional assessment tool, the Waterlow assessment, and a Barthel Scale of functional ability. Continence assessments have been undertaken for all who require one. Specialist mattresses were evident in the home. Specialist equipment is sought on an individual basis. Individual risk factors and restrictions are recorded. The staff work hard meet the individual needs of the service users, this was observed and confirmed by the service users. Two General Practitioners visited on the day of the inspection and service users confirmed that they were able to see the Doctor when they wished. The optician visits annually and the Dentist as required. The inspector and Manager discussed the need to formalise the arrangements for regular dental check ups. A new chiropodist is being arranged. The Administration of Medicines is undertaken by a qualified nurse at all times, medicines were observed to be handled and administered safely during a medicines round. No service users are currently administering their own medication. There is a Controlled Drugs cupboard and register to ensure the safe storage of Controlled Drugs. There is a trolley for medicines; this is stored in a locked room. Medicines were observed to be locked away. There is a designated fridge for medicines, which is in a locked room. The fridge temperature is checked and recorded. Handwritten Medication administration records (MAR) sheets must be signed by the person who copies them out and a second nurse must check them. A record is kept of all medicines entering and leaving the home. Unused medicines are disposed of safely using a clinical waste disposal company. The Policies and Procedures for medicines are due to be reviewed. The staff were observed to respect the Service Users privacy and dignity needs during the inspections. The staff were observed to knock on doors prior to opening them and use preferred names. All service users who spoke with the inspector commented on the kindness of the staff and felt that their privacy was respected. One double room has been provided with screening around the washbasin, as noted at previous inspections to promote privacy. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities are being developed to ensure that they meet the needs of the service users. Individual choices must be recorded within care documentation, to allow service users to exercise control and choice over their lives. Visitors are welcomed at the home. Service users are not being offered a choice of diet and the surroundings are not always conducive to an unhurried, relaxing meal. EVIDENCE: Most of the service users are frail and their ability to participate in some activities is restricted. The Manager has identified that this is an area for development and is appointing an activities coordinator to work three days a week 10.00-16.00. In February the range of activities provided were Old Time singing, Armchair dancing on two occasions, Pebbles the dog on two occasions and a residents meeting. There were no activities available on the day of the inspection and Service Users were non-committal about the activities in the home. Social interests and activities information must be gathered as part of the assessment and form the basis for planned activities in the home. Information must be circulated to the Service Users and posted on the notice Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 13 board. The importance of a centralised list of the activities and/or outings including who attends them was discussed. The home has an open visiting policy, the Inspector was advised that visitors welcome to visit any time depending on the service user’s wishes. Visitors were observed to be welcomed to the home on the day of the inspection, in a relaxed and friendly manner. Service users are able to maintain links with the community, visit family and friends as they wish. A Visitor Book is maintained. Relatives and friends are encouraged to be involved in the service user’s care depending on their wishes. A client’s profile is being developed for all residents, there should be evidence of service user’s choices about their daily life. Service users are encouraged to manage their finances, as they would wish. Individual accommodation was observed to be personalised. Service users informed the inspector that they felt able to make choices e.g. whether to eat in the dining room or in their room, whether to spend time with others or alone. The admission checklist includes cultural and religious needs have been ascertained. The menu on the day of the unannounced inspection was beef stew, mashed potatoes and green beans, battered fish was provided for the service users who did not like the stew. This was followed by fruit cocktail with clotted cream or Syrup sponge pudding and custard. No fresh fruit or vegetables were included in this meal. The menu is written up on the board in the dining room, only one of the service users who the inspector spoke to was aware of what was being offered for lunch. The inspector and Manager discussed the importance of service users being offered a choice, rather than an alternative if staff were aware that they did not like the main meal. This was also noted to be the same with fluids, all service users were provided with orange squash. Three service users have a cooked breakfast. There are several choices at teatime. The menu operates on an eight-week rotation. The head cook has the Intermediate food hygiene certificate and City and Guilds training. The cook is on duty until 2pm, the care staff serve the tea. There are no additional staff to undertake meal preparation, washing of dishes or serving of food. Food records are kept, these are currently under review. The inspector observed the mealtime in the dining room; ten service users ate at the dining room tables. Tables were laid up, although there were no napkins and clothes protectors were provided for all service users. The courses were observed to be served at different times for service users who were sat together, there were long gaps between the service and staff stopped serving to start assisting someone to eat their lunch. There was calling out from some individuals that clearly distressed or annoyed others. One service user left the dining room, but their dessert was served and was cold on their return. There was a delay in service users being able to leave the dining room to be seated comfortably. The inspector was informed that ‘food was often cold when it arrived’. Generally service users commented that they sometimes liked the food. On the day of the one service user commented that ‘the food was very nice’. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 14 Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their concerns would be acted upon. The staff receive training to ensure that they are aware of how to deal with any problems. Policies and Procedures are currently being reviewed and updated as part of the managerial audit of the home. EVIDENCE: The Commission for Social Care Inspection has not received any complaints or allegations about this home since the new registration. There is a complaints procedure for the home that includes the stages and who to contact including the Commission for Social Care Inspection and the Department of Adult Social Care. The procedure currently states that service users must go through the home procedures prior to contacting anyone else, this is being changed to state that service users are able to choose when or who to contact. Service users informed the inspector that they knew who to speak to if they had any concerns and were confident that it would be acted upon. A record is kept of any concerns or complaints and the outcome. The inspector was informed that the home is keen to work with families to meet the needs of their relative and regular face to face contact is part of that process. One service user told the inspector ‘I am happy with everything, if I wasn‘t I would tell them’. All staff are being provided with the Protection of Vulnerable Adults training in house. Four staff have attended the external training provided by Cornwall Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 16 County Council and four more are booked to attend this. The Policies and Procedures are being reviewed, the Registered Provider, Manager and inspector discussed the importance of having a clear procedure for POVA and Whistleblowing. Information is available within the home about detecting and reporting abuse. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation provided is comfortably and homely, there are areas that require updating and upgrading. This work is being planned. Service Users rooms are personalised and suit their needs. The home was clean and hygienic. EVIDENCE: Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 18 The home is comfortably furnished, in a homely way. The grounds are attractive and there is a car park at the front of the home. The home enjoys far reaching views across Bodmin and the countryside. The new Registered Person informed the inspector that there are plans to upgrade and develop the service, although this is not formalised as a programme of routine maintenance and renewal of fabric and decoration of the premises. This must be available for inspection. There are areas of the home that require updating and upgrading. At previous inspection there have been concerns regarding the dated appearance of the bathrooms. There are plans to update and improve these areas. There will be no reduction in the number of bathrooms and changes will be made depending on service user need. The limited amount of storage in the home has also been an issue, however solutions have and are being sought to improve this, to enable staff to work safely. There is a large lounge, small seating area for reading and a comfortable dining room. Furnishings are comfortable and domestic in character. There is adequate natural lighting and ventilation. A passenger lift is provided. Grab rails and other aids are provided. The Manager has recently undertaken an audit on the use of bed rails to ensure that they are only used when they are needed. The inspector and Manager discussed the issue of relatives consenting on behalf of a service user. Physical restraint must only be used if it is the only practicable means of securing the welfare of any person and there are exceptional circumstances. The circumstances must be recorded. A nurse call system is available to service users. Specialist equipment is sought on an individual basis. Bedrooms are generally small; there are fourteen single rooms and three double rooms. In one double room it is not possible for the Service User to access the wardrobe as the bed was up against it, this will need to be reviewed in the future. All rooms are provided with a lockable space and a lockable door. Adjustable beds are provided for service users receiving nursing care. Screening is provided in double rooms to ensure that both service users have privacy. The inspector was informed that radiators are safely guarded with low surface temperatures throughout the home and the water temperatures are controlled to reduce any risk to the service users. Lighting in Service Users rooms is domestic in nature. Rooms are naturally ventilated and have plenty of natural light. Service Users commented that their rooms were warm and comfortable. The laundry facilities are compact with one industrial washing and drying machines. All laundry is done in-house. The policies and procedures for COSSH and Infection Control related issues are all being reviewed. Disposable gloves and aprons are available to staff. The home was found to be clean on the day of the unannounced inspection. There are designated laundry and cleaning staff. Staff have been provided with new uniforms. There is a sluicing Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 19 facility on the first floor of the home. The home was free from odours on the day of the unannounced inspection. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are being provided with the skills and knowledge that they require to meet the service user’s needs. There is a robust recruitment and selection process to ensure the Service Users are protected and their needs are met, in an individual and collective way. Service users value the staff and speak highly of them. EVIDENCE: The staffing levels have been reviewed and increased since the last inspection. On the morning of the Unannounced Key inspection there was a qualified nurse, five carers, a cleaner, cook and Manager. In the afternoon there is one nurse and three carers on duty, at night there is one nurse and one carer. There is a qualified nurse on duty at all times in the home. There is a recorded staff rota, which shows the staff that are on duty at any given time. No one under eighteen is employed at the home. There are designated cleaning and catering staff. Service users told the inspectors that staff could meet their needs, ‘they often just pop in to see me’. Five out of thirteen care staff have achieved their National Vocational Qualification level 2 qualification, this is 34 . Two carers are qualified nurses in Latvia and are registered in this country, are due to commence their National Vocational Qualification level 3. Two carers are qualified nurses in Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 21 China. This would mean that over fifty percent of the carers have National Vocational Qualification level 2 or equivalent. There is a thorough recruitment procedures including the completion of an application form, obtaining two written references, health declaration, Criminal Records Bureau check, POVA first and attendance for an interview. Staff files are well organised. The importance of interview records being kept was discussed. One service user informed the inspector that ‘the staff are very good’. A comprehensive induction is offered to all new staff and all staff have a training file. The Manager has worked hard to prioritise the backlog of training for the care staff to include Manual Handling, Fire, Emergency First Aid and the Protection of Vulnerable Adults. Further work is needed and the Manager is committed to ensuring that all staff have the skills and knowledge that they require to meet the needs of the service users. Two staff are doing National Vocational Qualification level 2 and four are doing level 3. Two staff are due to commence their A1 Assessors Course. All staff are provided with an Employees Handbook. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The managerial and administrative systems are improving significantly to meet the needs of the service users and to support the staff delivering the care. The ethos of the home is clearly to establish systems that are driven by the wish to provide a high standard of individualised care. The Manager has been in post for four months and the new owners for seven months, a significant amount has been achieved and the momentum to continue these improvements was evident. Environmental risk assessments must be in place. EVIDENCE: The Manager, Mrs. Carol Edwards was appointed just over four months ago and is a registered nurse with thirty years within the care sector. Carol Edwards has ten years experience of working with older people and older Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 23 people with mental health problems. The Manager has submitted her application, which is currently being considered for registration, to enable her to be the Registered Manager at Castle Hill House. Carol Edwards has completed her Registered Manager’s Award, A1 Assessors Award, ENB 993 and is a Fire Warden. There is clear evidence of leadership and management systems in place. The inspector observed a notable change in the running of the home. This was confirmed by staff that commented on the number of positive changes to the running of the home over the last seven months. The inspector was informed by service users and staff that the responsible individual Mrs.Wielkopolska visits the home regularly. Regulation 26 visits are conducted and copies of the report are provided to the Commission for Social Care Inspection. There has been a lot of change over the last seven months, this has been made smoother by regular communication and accessibility, the inspector was informed. There are staff meetings, where staff are able to contribute their views to the running of the home. Minutes are kept of these meetings for staff who are unable to attend. Due to the considerable amount of work needed, the Responsible individuals and Manager have had to prioritise the work. A lot of hard work has been started to improve the standards of management and administration. The Policies and Procedures were previously standardised, they are due to be reviewed and updated. Evidence that staff have read and understood them will be gathered when they are completed. The Manager has audited all aspects of the home including care documentation, the environment and activities. A formalised quality monitoring system has yet to be introduced, but is planned for later this year. Service user and relative meetings have started and another one is booked. These meetings have minutes taken and these are readily available for anyone who did not attend in the reception hall. The service user is encouraged to manage their own financial affairs. Some families support their relative and some have a small amount kept in the home for any expenditure. A record is kept of any monies held, this includes the amount deposited, withdrawn and the balance. Signatures are gained for any expenditure. Receipts must be kept for any items purchased. A Procedure for the Safe Handling of Service Users Monies is needed. The Manager undertakes random checks to ensure that monies are handled correctly. Supervision for the staff has been started. Records are kept of sessions and include all aspects of practice. The Manager is planning for care staff to receive supervision six times annually to include an appraisal. There is evidence that routine maintenance and servicing is being undertaken. The gas was serviced in March 2007, Portable Appliance testing took place in January 2007 and hard wiring in February 2003. The inspector was informed that hot surfaces are covered and windows are restricted. There is a Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 24 maintenance person who works evenings and weekends. The environmental risk assessments are being developed, this area should be prioritised. Risk assessments must be completed for all identified risks within the home. The Fire Officer visited the home on the 24th of May 2006 and advised that the risk assessment needed to be more detailed. All staff are provided with the Health and Safety handbook as part of their induction, they sign to say that they have read and understood. Further Fire, health and safety and fire training is booked for the 13th of March and 15th of July. The Manager is arranging moving and handling and Fire training for all staff. Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 25 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 X 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 3 3 3 X 3 3 x 2 Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement Timescale for action 01/09/07 2. OP1 4, Sch.1 3. OP12 16(2n) 4. OP15 16(2i) The Registered Person shall produce a written guide to the care home, a copy must be supplied to each service user and the Commission for Social Care Inspection. The Registered person shall 01/09/07 compile in relation to the care home a written statement of purpose including the required information. A copy must be supplied to the Commission and make a copy available for inspection by every service user. The registered person must 01/09/07 consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of the service users, activities in relation to recreation, fitness and training. The registered person shall 01/09/07 provide in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and DS0000054294.V318059.R01.S.doc Version 5.2 Castle Hill House Limited Page 27 5. OP38 13(4) available at such time as may be reasonably required by service users. The Registered Person shall ensure that the home is so far as practicable free from hazards to their safety and unnecessary risks to health or safety of Service Users are identified and so far as possible eliminated. 01/09/07 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. 2. Refer to Standard OP9 OP12 Good Practice Recommendations For the transcribed medication prescription to be checked and signed by a second nurse. For activities to be based upon Service Users interests, up to date information about the activities that are available in the home to the circulated to all Service Users and posted on the notice board. For there to be a clear procedure for the Protection of Vulnerable Adults to enable staff to know the action that they must take. 3. OP18 Castle Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Hill House Limited DS0000054294.V318059.R01.S.doc Version 5.2 Page 29 - 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!