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Inspection on 09/02/06 for Castle Hill House Limited

Also see our care home review for Castle Hill House Limited for more information

This inspection was carried out on 9th February 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Inspectors were impressed with the friendliness and hard work being demonstrated by the care staff. The communal accommodation and reception area of the home is well decorated and welcoming. The local Primary Health teams provide a high level of support to the home.

What has improved since the last inspection?

Since the last inspection there is evidence that POVA First checks are being obtained on all staff prior to them commencing work.

What the care home could do better:

The Inspectors were concerned about the apparent lack of detail in the pre admission information that is gathered by the home prior to the Service User moving into the home, particularly considering the Service User`s high level of needs. It is recommended that a full assessment undertaken by a person who is trained to do so gathers the information listed in National Minimum Standard (NMS) 3.3. prior to the Service User being admitted to the home. Due to the complexity of needs of the Service Users, the Inspectors felt that the plan of care was not in sufficient detail to direct care. There was no evidence that a comprehensive assessment had been drawn up with each Service User and that this provided the basis for the care to be delivered, in the Service User records that were inspected. There was no evidence that the Service User had been involved in the drawing up of the plan or that it had been agreed or signed by the Service User and/or representative, in mostcases. Assessment tools are used within the home, however these appear to be isolated documents, rather than incorporated into the care planning process. These documents must be reviewed and provide sufficient information to direct the care delivery. Tissue Viability and wound care information was noted to be inadequate for the most dependent service users. Risk assessing is undertaken for all Service Users, this must be supported by a risk management plan. Clarification has been sought about the numbers of service user who fall into the category of suffering from Dementia. Several curtains and carpets were noted to be in need of replacement in Service Users rooms. An audit of bed linen is required as it was observed to be threadbare. The bathrooms were noted to be dated and in need of refurbishment. A programme of routine maintenance and renewal of fabric and decoration of the premises will be inspected at the next inspection. The lack of screening in one double room would not allow a Service User to use the wash hand basin for washing in private. One toilet was being used for storing mattresses and another bathroom was noted to be used for storage. There must be adequate storage within the care home. The Service User`s records must be securely stored away. The environmental risk assessments must be reviewed, updated and completed for all risks within the home. Fire training and procedures must be prioritised. The Inspectors were concerned regarding the management arrangements for the home, as they were informed although the Registered Provider who is registered as the Registered Manager is in contact with the home, they do not manage the home on a full time day-to-day basis. There is no evidence that staff have been provided with a thorough induction, the induction booklet utilised does not include the Skills for Care standards. There must be a staff training and development programme that fulfils the requirements. Staff files do not demonstrate evidence that the staff have been offered the training that they need to do their jobs safely and competently for example fire, foundation food hygiene, first aid, infection control, health and safety, dementia training. Moving and handling training has been provided for staff in house and evidence of the trainer`s qualification is being sought.

CARE HOMES FOR OLDER PEOPLE Castle Hill House Limited Castle Hill House Castle Hill Bodmin Cornwall PL31 2DY Lead Inspector Kerensa Livingstone Unannounced Inspection 9th February 2006 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.V277398.R01.S.doc Version 5.1 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.V277398.R01.S.doc Version 5.1 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 Mrs Judith Ann Adams 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 (20), Terminally ill (20) Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 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 terminal illness (TI{E}) 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 12th October 2005 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). The home is registered to take Service Users who require terminal care (TI) or have a Physical Disability (PD). The entrance to the front of the home is locked. One of the Registered Providers is the Registered Manager with responsibility for managing the home on a day-to-day basis. The two Providers live in a separate building on the same site and are supported on a day-to-day basis by a Deputy Manager. The home is an 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.V277398.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors, one of whom has visited the home previously over a full day, conducted this Unannounced Inspection. During the inspection the Inspectors had the opportunity to speak with all the staff and meet service users, inspect the environment and documentation. Unfortunately due to the Unannounced nature of the inspection the Providers were both in training for the morning and were unable to contribute during the inspection due to other appointments. The Inspectors had the opportunity to see them briefly at the end to gain access to staff records. Therefore some evidence and points have been clarified since the inspection by the Lead Inspector. What the service does well: What has improved since the last inspection? What they could do better: The Inspectors were concerned about the apparent lack of detail in the pre admission information that is gathered by the home prior to the Service User moving into the home, particularly considering the Service Users high level of needs. It is recommended that a full assessment undertaken by a person who is trained to do so gathers the information listed in National Minimum Standard (NMS) 3.3. prior to the Service User being admitted to the home. Due to the complexity of needs of the Service Users, the Inspectors felt that the plan of care was not in sufficient detail to direct care. There was no evidence that a comprehensive assessment had been drawn up with each Service User and that this provided the basis for the care to be delivered, in the Service User records that were inspected. There was no evidence that the Service User had been involved in the drawing up of the plan or that it had been agreed or signed by the Service User and/or representative, in most Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 6 cases. Assessment tools are used within the home, however these appear to be isolated documents, rather than incorporated into the care planning process. These documents must be reviewed and provide sufficient information to direct the care delivery. Tissue Viability and wound care information was noted to be inadequate for the most dependent service users. Risk assessing is undertaken for all Service Users, this must be supported by a risk management plan. Clarification has been sought about the numbers of service user who fall into the category of suffering from Dementia. Several curtains and carpets were noted to be in need of replacement in Service Users rooms. An audit of bed linen is required as it was observed to be threadbare. The bathrooms were noted to be dated and in need of refurbishment. A programme of routine maintenance and renewal of fabric and decoration of the premises will be inspected at the next inspection. The lack of screening in one double room would not allow a Service User to use the wash hand basin for washing in private. One toilet was being used for storing mattresses and another bathroom was noted to be used for storage. There must be adequate storage within the care home. The Service Users records must be securely stored away. The environmental risk assessments must be reviewed, updated and completed for all risks within the home. Fire training and procedures must be prioritised. The Inspectors were concerned regarding the management arrangements for the home, as they were informed although the Registered Provider who is registered as the Registered Manager is in contact with the home, they do not manage the home on a full time day-to-day basis. There is no evidence that staff have been provided with a thorough induction, the induction booklet utilised does not include the Skills for Care standards. There must be a staff training and development programme that fulfils the requirements. Staff files do not demonstrate evidence that the staff have been offered the training that they need to do their jobs safely and competently for example fire, foundation food hygiene, first aid, infection control, health and safety, dementia training. Moving and handling training has been provided for staff in house and evidence of the trainer’s qualification is being sought. 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 Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 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.V277398.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Service Users must be provided with up to date accurate information to enable them to make an informed choice about where they live. EVIDENCE: The Statement of Purpose is a comprehensive document detailing the aims of the home. The Inspectors were concerned that some aspects of the information did not seem to equate with the Service Users experience for example that a three course lunchtime and tea time meal is available, and the dentist and optician visit the home regularly. The frequency of reviewing the care plans should be included, as identified at previous inspections and there are some issues that require clarification for example whether any clergy visit the home and how often. The Service Users Guide includes information about the Statement of Purpose, Service Users comments, contracts and the complaints procedure. Both documents must be updated regularly particularly with changing staff. The Complaints Procedure must be updated to state that the complainant can contact the Commission at anytime. Both documents are available in the reception of the home, with copies of the reports dating back to 2003. All prospective Service Users must be provided with this document; Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 9 the Inspectors were informed that a copy of this document is not always provided. A copy of each of these reviewed documents must be forwarded to the Commission for Social Care Inspection. Service Users contracts include terms and conditions of living at Castle Hill House. Service Users contracts should include a breakdown of the fees and whom is responsible for paying them. One relative informed the Inspector that they had not been provided with a contract. The Inspectors were concerned about the apparent lack of detail in the pre admission information that is gathered by the home prior to the Service User moving into the home, particularly considering the Service Users high level of needs. It is recommended that a full assessment undertaken by a person who is trained to do so, gather the information listed in National Minimum Standard (NMS) 3.3. prior to the Service User being admitted to the home. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Service Users plans of care must be in sufficient detail to direct care including all aspects of physical care, psychological, spiritual and social needs. These must be based upon a thorough assessment and drawn up with the Service User and/or their representative. Medicines were administered safely. EVIDENCE: Each service user has a care plan, which is problem based and computer generated. These are review monthly. Due to the complexity of needs of the Service Users, the Inspectors felt that the plan of care was not in sufficient detail to direct care. There was no evidence that a comprehensive assessment had been drawn up with each Service User and that this provided the basis for the care to be delivered, in the Service User records that were inspected. There was no evidence that the Service User had been involved in the drawing up of the plan. or that it had been agreed or signed by the Service User and/or representative. One relative commented that they would like to be more involved in this process. At previous inspections the Inspector and Registered Providers have discussed the importance of including social, spiritual and psychological aspects of an individual’s needs, this is yet to be done. All Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 11 Service Users have a keyworker. A daily record is kept, this recording should be improved to ensure that clear information is communicated. All Service Users are registered with a General Practitioner. The home report 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 these are produced by the Deputy Manager. However these appear to be isolated documents, rather than fully incorporated into the care planning process. Staff did not appear to be involved in this process. These documents must be reviewed and provide sufficient information to direct the care delivery. Care staff support or maintain the personal hygiene of the Service Users depending on their level of need. Tissue Viability and wound care information was noted to be inadequate for the most dependent service users. Specialist equipment is sought on an individual basis. Risk assessing is undertaken for all Service Users, this must be supported by a risk management plan. Psychological, social, spiritual and physical needs should be monitored and preventative and restorative care provided. Individual Service Users healthcare needs are generally met and there is evidence of medical review. The Inspectors could find little evidence at inspection that there were regular visits from the Optician and Dentist The home has detailed medication Policies and Procedures, these need to be updated to comply with changing legislation. Medication administration records are completed accurately and medicines are stored appropriately. 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. There is a Controlled Drugs cupboard and register to ensure the safe storage of Controlled Drugs. There is a designated fridge for medicines, this must be kept locked or in a locked room. The temperature was not within acceptable limits. The fridge temperatures should be monitored and recorded. These issues have been raised at a previous inspection. Vaccinations were observed to be being kept in a warm room, it recommended that advice is sought from the Pharmacist as these need to be stored at below 8 degrees. Staff were observed to respect the Service Users privacy and dignity needs during the inspections. Staff knocked on doors prior to opening them. Several Service Users commented on the kindness of the staff. One double room has no curtains or screening around the washbasin, as noted at previous inspections. This would prevent Service Users having the option of sitting at the wash hand basin. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected at this inspection. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The Inspectors could not find evidence that concerns or complaints were monitored and acted upon. Staff are not aware of the actions to take if there is an allegation of abuse. Service Users would be assisted to participate in the electoral process and advocacy information is made available. EVIDENCE: The home has a complaints procedure, which details the action required, this includes stages and timescales. It is recommended that this include that the Complainant may refer their complaint to the Commission for Social Care Inspection at any time. A record of all complaints, including the investigation undertaken and action taken should be kept. Information is included in the Statement of Purpose about the Service Users having a right to vote. Service Users would be facilitated on an individual basis to seek the support that they needed. Information about advocacy services is available on a board within the home. A procedure detailing the action to be taken in the event that an incident of abuse being alleged is required including local contact details and all staff must receive training to ensure that they are aware of the action to be taken. At inspection staff had not received training and were not aware of the action to be taken. The Registered Person shall make arrangements, by training all staff or by other measures to prevent Service Users being harmed or suffering abuse or being placed at risk of harm or abuse. Four staff including the Registered Manager have attended the Social Services facilitated training. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 14 Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 22, 23, 24, 25 & 26 Some of the Service Users accommodation needs redecorating and all toilet/bathroom facilities require upgrading. Individual Service Users rooms are personalised and suit their needs. The communal areas are comfortable and homely. EVIDENCE: Several curtains and carpets were noted to be in need of replacement in Service Users rooms. An audit of bed linen is required as it was observed to be threadbare in some Service Users rooms. The bathrooms were noted to be dated and in need of refurbishment. A programme of routine maintenance and renewal of fabric and decoration of the premises will be inspected at the next inspection. There is a passenger lift. One toilet was being used for storing mattresses and another bathroom was noted to be used for storage. There must be adequate storage within the care home. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 16 Bedrooms are generally small, there are fourteen single rooms and three double rooms. In one room the Inspectors observed it was not possible for the Service User to access the wardrobe as the bed was up against it. Service Users rooms are furnished individually and provided with the required furnishings. Adjustable beds are provided for Service Users receiving nursing care. The Inspectors observed that all beds appeared to have cot sides on them, however no risk assessment or documentation pertaining to them in the Service Users notes. Rooms are fitted with door locks and a lockable space provided, however the home’s Procedure for the Safe handling of monies and valuables states that ‘money will not exceed £25 for each Service User and all cash will be kept in a locked safe’. Some curtains were observed to need rehanging and some carpets are due to be replaced. The lack of screening in one double room would not allow a Service User to use the wash hand basin for washing in private. Radiators are safely guarded with low surface temperatures throughout the home and the Providers have informed the Inspector that 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 internally. Policies and procedures are in place for the safe storage of chemicals and Infection Control related issues. Disposable gloves and aprons are available to staff. The home was found to be generally clean on the day of the unannounced inspection; there were some Service Users rooms that required some cleaning. There were several areas in the home that were odorous. There are two staff that undertake the laundry and cleaning. Staff were observed to be professionally attired in a uniform. There is a sluicing facility on the first floor of the home. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The recruitment procedures are robust. Following recruitment difficulties, there appear to be gaps in the induction and foundation training that is provided to the staff. Staff must be provided with the knowledge and skills that they require to enable them to care competently for the Service Users. EVIDENCE: There is a qualified nurse on duty at all times in the home. The housekeeping staff member is included on the rota as are the catering staff. There are three care staff on each morning and two each afternoon, in addition to a qualified nurse during the week. At inspection the rota indicated that at weekends this drops to one nurse and two carers in the morning, since the inspection the Inspector has been advised that the levels remain over a seven day period. These staffing levels appear to be a reduction from a previous inspection, therefore clarification is being sought. The care staff were observed to undertake the laundry as part of their roles. A gardener comes in to maintain the garden. There is a recorded staff rota which show the staff are on duty at any given time, however the Registered Person is not shown on the duty rota. The Inspectors have been informed that the Registered Person is not managing the home on a fulltime day to day basis, if this is not the case a Registered Manager must be appointed under Regulation 8 of the Care Homes Regulations 2001. Staff records are in place to evidence that two written references are being taken prior to employment of new staff. All new staff complete an application Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 18 form and sign a health declaration. In the files examined, all staff have had Criminal Records Bureau checks undertaken by the Providers. The home has an Equal Opportunities policy and procedure. The Provider is aware that no staff are able to commence employment without the POVA initial check having been received. Evidence of interview questions and answers should be kept. Registration details are checked with the Nursing and Midwifery Council as required. Recruitment difficulties have resulted in the use of recruitment agencies attracting staff from abroad, the Registered Providers must ensure that the communication difficulties observed during the unannounced inspection are addressed. Service Users spoke highly of the care staff. There is no evidence that staff have been provided with a thorough induction, the induction booklet utilised does not include the Skills for Care standards. There must be a staff training and development programme that fulfils the requirements. Staff files do not demonstrate evidence that the staff have been offered the training that they need to do their jobs safely and competently for example fire, foundation food hygiene, first aid, infection control, health and safety, dementia training. Moving and handling training has been provided for staff in house. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 37 & 38 The Inspectors are concerned regarding the day-to-day management and leadership within the home. EVIDENCE: Policies and Procedures are standardised and dated 2002, these should be reviewed and updated, evidence that staff have read and understood them should be obtained. Evidence of financial viability and Insurance cover for the home has been provided as a routine part of the annual inspection process. The Inspectors have been advised that there has been reinvestment in the home since the last inspection. Service Users records were observed to be left in the dining room and kept in an open box in the office. The records must be securely stored away. There is Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 20 a visitor’s book and accidents are recorded in an accident book, the pages must be removed to ensure that this recording complies with data protection legislation. At inspection staff were not aware of where the environmental risk assessments were kept. The environmental risk assessments must be reviewed, updated and completed for all risks within the home. The Fire book recorded that no weekly fire testing had taken place since the 6/12/05 and fire doors were checked on the 12/9/05 and Emergency lighting was checked 1/12/05. There was no evidence that staff had received fire training, twice yearly for the day staff and three times yearly for the night staff. Extinguishers were checked in April 2005.There is evidence that equipment is serviced regularly and Gas certification has been provided since the inspection dated 13.2.06. The Inspector has been advised that annual Portable Appliance testing is undertaken on all electrical items. There is no evidence of an annual Fire Officer visit and this should be requested. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 21 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 2 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 1 X X 2 2 3 2 3 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 x 3 x x 2 2 Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 22 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 OP1 Regulation 6 Requirement The Registered Person shall keep under review and where appropriate revise the Statement of Purpose and the Service Users Guide. The Registered Persons must compile a Statement of Purpose that shall consist of a statement as to the facilities and services that are to be provided in the home as listed in Schedule 1. A copy must be provided to the Commission. The registered person shall not provide accommodation to a Service User at a care home unless the needs of the Service User have been assessed by a suitably qualified person and there has been appropriate consultation with the Service User or representative. The registered person shall confirm in writing that the care home is suitable for meeting the needs of the Service User in respect of his health and welfare. The Registered Person shall after consultation with the Service DS0000054294.V277398.R01.S.doc Timescale for action 01/05/06 2. OP1 4, Sch. 1 01/05/06 3. OP3 14(1) 01/04/06 4. OP7 15 01/04/06 Castle Hill House Limited Version 5.1 Page 23 5. OP8 13(4) 6. OP16 22 7. OP18 13(6) 8. OP21 23(2d) 9. OP22 23(2l) 10. OP24 23(2d) User, or representative prepare a written plan as how the Service Users needs in respect of his health and welfare are to be met. This document must in be sufficient detail to direct care. 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 The Registered Providers must ensure that a record is kept of all complaints, including the investigation undertaken and action taken. The Registered Person shall supply the Commission for Social Care Inspection with a statement containing a summary made during the preceding twelve months and the action taken in response forthwith. The Registered Person shall make arrangements, by training staff or by other measures to prevent Service Users being harmed or suffering abuse or being placed at risk of harm or abuse. The Registered person shall having regard for the number and needs of the Service Users ensure that all parts of the care home are kept clean and reasonably decorated for example the bathrooms and toilet facilities. The Registered person shall having regard for the number and needs of the Service Users ensure that there is suitable storage for the purposes of the care home. The Registered person shall having regard for the number DS0000054294.V277398.R01.S.doc 01/04/06 01/04/06 01/04/06 01/05/06 01/05/06 01/04/05 Page 24 Castle Hill House Limited Version 5.1 11. 12. OP26 OP30 16(2k) 18(1) 13. OP32 8(1) 14. OP32 21(2) 15. OP33 24(2) 16. OP37 17(1b) 17. OP38 13(4) and needs of the Service Users ensure that all parts of the care home are kept clean and reasonably decorated for example the window, curtains and carpets. The Registered Person shall keep the home free from offensive odours. The Registered Providers must make arrangements for new staff to undertake a National Training Organisation (Skills for Care – www.topssengland.net) compliant induction programme, and for providing training to care staff appropriate to the care provided in the home. The Registered Provider shall appoint an individual to manage the care home where they are not, or does not intend to be, in full time day-to-day management of the care home. The Registered person shall make arrangements to enable the staff to inform the registered person and the Commission of their views about any matter relating to the conduct of the home. The Registered Person shall supply to the Commission a report in respect of any review conducted for the purposes of establishing and maintaining a system for reviewing the quality of care. This information must be made available to the Service Users. The Registered Person shall ensure that the Service User’s records are kept securely in the home. The Registered Person shall ensure that the home is so far as practicable free from hazards to their safety and unnecessary DS0000054294.V277398.R01.S.doc 01/03/06 01/05/06 01/04/06 01/05/06 01/04/06 09/02/06 01/04/06 Castle Hill House Limited Version 5.1 Page 25 risks to health or safety of Service Users are identified and so far as possible eliminated 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. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP2 OP3 OP7 OP7 OP8 OP9 OP9 OP10 OP16 Good Practice Recommendations For the statement of terms and conditions to include a breakdown of fees and whom is responsible for paying them. For the information listed in NMS 3.3. to be gathered during the pre admission process. For the Service Users/their representative to sign to demonstrate their involvement in the planning of care. For psychological, spiritual and social aspects to be detailed within the Service Users plan of care. For the documentation to be reviewed to ensure clear concise and comprehensive information is recorded e.g. tissue viability, wound care. To ensure that the medicines fridge is lockable or in a locked room. The fridge temperatures should be recorded. For the Administration of Medicines Policies and Procedures to be reviewed and evidence to be gathered that staff have read and understood them. For screening to be provided around the sink in the double room, to enable the Service User the option to wash at the wash hand basin. For the Complaints Procedures to be reviewed, as there were two different ones at inspection, they both should state that the complainant may contact the Commission at anytime. The preferred PoVA procedures should be obtained from the funding authority where a service user comes from outside Cornwall. For cotsides to be used as per the home’s Policies and Procedures, based upon clear risk assessment information For an audit into the quality of bed linen to be conducted and replaced as deemed appropriate. For a record of the interview questions and answers to be kept. DS0000054294.V277398.R01.S.doc Version 5.1 Page 26 10. 11. 12. 13. OP18 OP22 OP24 OP29 Castle Hill House Limited 14. OP33 For the Policies and Procedures to be reviewed and updated. Castle Hill House Limited DS0000054294.V277398.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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. 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