Inspection on 01/11/07 for Castlemead Court Care Centre

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Castlemead Court Care Centre 30/11/09

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Castle Mead Court Wolverton Road Newport Pagnell Buckinghamshire MK16 8HW Lead Inspector Joan Browne Unannounced Inspection 1st November 2007 10:30 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 Mead Court DS0000070221.V349665.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 Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Mead Court Address Wolverton Road Newport Pagnell Buckinghamshire MK16 8HW 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) 020 8313 5000 Excelcare Holdings Vacant Care Home 79 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 79. Date of last inspection N/A Brief Description of the Service: Castlemead Court is a care home built in 2007. It is situated on three floors and located on the northern side of Milton Keynes in Newport Pagnell. The town centre is a short walking distance from the home and there are a range of local and high street shops, restaurants and other facilities. The local buses give access to many other areas in Milton Keynes and the centre of Milton Keynes is only a short bus ride away. Excelcare Holdings Ltd owns the home. It provides personal and nursing care for up to seventy-nine service users. It is separated into three units. Each unit has its own sitting, dining and kitchenette area. Bedrooms are single occupancy with en–suite facilities. There are also a number of therapy rooms such as, hairdressing, computer with internet access, a sensory and prayer room. There is a passenger lift, which permits access to all levels of the home. Grab rails are found in toilets, bathrooms and bedrooms. The home possesses hoisting equipment to facilitate safe moving and handling practice. There is a nurse call system in place. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 5 There is an enclosed garden, which is secure to provide a safe environment for service users. Within the garden there is a large established pond. At the rear of the building there is a secure patio garden. At the front of the building there is decking leading out to the pond. The staff team consists of trained nurse, carers, housekeeping, catering, laundry, administrative and maintenance staff. The fees for this service range from £575.00-£700.00 per week. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ and was carried out on 1 November 2007. The inspector spent approximately seven ½ hours in the service and looked at how well the service was doing. The inspection took into account detailed information provided by the service’s manager. Comment cards were sent to some service users, relatives and health and social care professionals. At the time of writing this report response to comment cards were received from nine relatives and one health care professional. Their views and those of service users and staff spoken to during the inspection have been reflected in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Care plans were examined, which was followed by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with staff rosters, staff recruitment files, training records and health and safety records. A tour of the premises was carried out and some time was spent meeting with service users and staff. At the end of the inspection feedback was given to the general manager and the operations manager. From the evidence seen it was considered that the home was providing a good service to meet the diverse needs of individuals of various religion, race and culture. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: Prospective people to use the service have their needs assessed prior to moving into the home to ensure that the home is able to meet the assessed needs. People using the service have a care plan detailing how all aspects of their health, personal and social care needs should be met. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 7 The lifestyle in the home suits people using the service including their preferences, cultural, religious and recreational needs. People using the service are encouraged to maintain contact with family and friends. Visitors are welcomed at the home. People using the service are provided with wholesome and nutritious meals in pleasing surroundings. There is a complaints procedure to ensure that people using the service will be confident that their complaints would be listened to, taken seriously and acted upon. People using the service live in a safe well-maintained environment, which is clean, pleasant and hygienic. The home has been designed with reference to relevant guidance to meet individuals’ diverse needs. The home’s recruitment procedure complies with current legislations to ensure that people using the service are looked after by staff who have been appropriately recruited. The home has a quality assurance system in place to ensure that it is run in the best interests of people using the service. What has improved since the last inspection? What they could do better: It is recommended that in the interests of safety and to comply with best practice guidelines any alterations or additions in people using the service care plans should be dated and signed in such a way that the original entry can still be read clearly. It is recommended that in the interests of safety and to minimise the potential risk of error being made when transcribing the service must ensure that handwritten entries recorded on people using the service medication administration record sheets should be countersigned by a second staff member. It is recommended that in the interests of safety and to comply with best practice guidelines staff must not write or scribble over entries on the medication administration record (MAR) sheets because the sheets are legal documents and can be used in court or in an investigation. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 8 It is recommended that in the interests of people using the service safety and to comply with the current infection control guidance to minimise the risk of cross infection individuals requiring hoisting should not use shared slings. 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 Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 9 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 Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 10 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&3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that prospective people to use the service have an assessment of their care needs, which they or people close to them have been involved in. Written contracts are issued to individuals, which outline fee payments, terms and conditions of residence and what the home provides for the money. EVIDENCE: The home has a statement of purpose and service user’s guide. The documents were written in plain English and in large print detailing the aims, objectives, philosophy of care and the facilities to be provided. A copy of the service user’s guide and statement of purpose is routinely given to prospective service users at the pre-admission assessment. This ensures that individuals are fully aware of the facilities provided and would be confident that the home is able to met their diverse needs. It was noted that work was in progress to Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 11 develop the home’s brochure further to ensure it was more user friendly with more photographs. Case tracking confirmed good practice. Prospective service users and their representative are made aware of the services and facilities that the home is able to provide. There was evidence in the three care plans examined confirming that prior to admission individuals were visited by a staff member in their own home or in hospital and an assessment of their care needs had been undertaken. The home encourages prospective service users and family members to look around the home before taking up occupancy. The three service users whose care was case tracked said that their relative or representative had visited the home and looked around and were happy with the facilities. One service user said ‘it’s a new home and everything is perfect.’ A second service user said ‘my room is lovely, I chose it and I can choose to do what I like.’ Staff spoken to were able to describe the admission procedure and the importance of making sure that new service users felt welcomed. For one individual who was referred through care management arrangements a summary of the care management assessment had been obtained. There was enough written information recorded in all three pre-admission care documentation records examined for staff to meet the social, emotional, health and personal care needs of individuals. The manager said that each service user was issued with written contracts, fee payments and terms and conditions of residence. Copies of these documents were kept in a separate folder and stored in the manager’s office. Respondents to the Commission’s comment cards said that the home ‘always’ or ‘usually’ provided enough information about the facilities provided in the home. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 12 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that the health and personal care that people using the service receive is based on their diverse needs. Inconsistencies in staff’s medication practice have the potential to put people using the service at risk and need to be improved. EVIDENCE: Three care plans were examined. They contained detailed action planning on how individuals’ health and social needs should be met by staff. Risk assessments relating to moving and handling, nutrition, and tissue viability (skin integrity) were in place. There was written evidence seen, reflecting that individuals’ weights and care plans were monitored monthly or as and when required. The plans for the three service users whose care was case tracked were signed by individuals and their representatives, which confirmed their involvement in their development. All the staff spoken to were able to describe how they used and help developed care plans. They accurately described the plans for the individuals whose care was case tracked. This knowledge means Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 13 that service users can be confident that they will get support from people who understand their care needs. Some written over entries were noted in the care plan for a particular service user. It is recommended that the practice of writing over entries should be reviewed. Any alterations or additions in the care plan should be dated and signed in such a way that the original entry can still be read clearly. Relatives who responded to the Commission’s comment cards said that the home ‘always’ or ‘usually’ provided the agreed support as reflected in the care plans. Those service users spoken to during the inspection visit said that they were happy with the standard of personal care provided by staff members. All service users were registered with a general practitioner of their choice. On the day of the inspection the majority of service users in the home were registered with the local general practitioner surgery and weekly visits were being undertaken. Service users also have access to health care facilities such as, dental, chiropody and optical. Professional advice about the promotion of continence is sought and acted upon and aids and equipment needed are provided. It was noted that there were no service users living in the home on the day of the inspection that were suffering from pressure ulcers. Service users who responded to the Commission’s comment cards said that they ‘always’ or ‘usually’ receive the medical support needed. The following comment was noted from a relative who responded to the Commission’s comment cards: ‘The home is very good at keeping me informed of mum’s health care. They ring if they have any problems with mum.’ A health care professional made the following comments- ‘The home appears to be well run and well organised.’ The medication administration record sheets were viewed and no unexplained gaps were noted. One service user informed the inspector that she was selfadministering her medication. The appropriate risk assessment was in place and the individual was provided with a lockable storage space in which to store the medication and was happy with the support provided by staff members. The controlled drug medication was checked and all medication was accounted for. Some inconsistencies in staff’s practice were noted. For example, handwritten entries on the medication administration record (MAR) sheets were not always checked by two staff members to make sure that they were correct and to minimise the risk of error when transcribing. Written over entries were noted on some MAR sheets which made it look like medication was signed for before being offered to individuals. This practice has the potential to put service users at risk. Staff were observed interacting appropriately with service users and were seen knocking at doors before entering. Individuals preferred term of address was recorded in care plans seen. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 14 Service users looked well groomed with attention to detail and were enabled to wear their jewellery and make up. There was a telephone facility in place for individuals to make and receive calls and some service users had their personal telephones installed in their bedrooms. All rooms were single occupancy to ensure that individuals’ privacy and dignity were not compromised. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The home ensures that people using the service are able to make choices about their religious and personal interests. They are encouraged to maintain links with family members and to be part of the local community. Meals provided are varied, appealing, wholesome and nutritious served in pleasing surroundings. EVIDENCE: Service users spoken to said that they were able to exercise choice in relation to leisure activities, cultural interests, religious observance and daily living activity routines. This was evidenced in care plans seen. Some time was spent with the activity organiser and she explained in detail the planned activity programme that was in place. Service users participate in activities twice daily if they wished to. Some activities on offer were board games, bingo, reminiscence, quizzes and baking, which has proved to be very popular. Each month an outside entertainer is booked to perform to service Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 16 users. Hairdresser and beauty therapists visit the home regularly. The home networks with a home owned by the same organisation and arrangements were in place for service users to attend bingo sessions and tea parties at the home. One to one activities were being provided to those service users who did not wish to participate in the large group activity or were being nursed in bed. On the day of the inspection one service user was escorted on a shopping trip to the town centre by the activity organiser. Provision was in place for individuals to visit the local library if they wished to. A record was maintained of individuals’ activity choices and preferences, which was evidenced in care plans examined. The home celebrated Halloween and some individuals spoken to were complimentary about the support given by staff members to ensure that the celebration was successful. They were now looking forward to celebrating Guy Fawkes. It was noted that work was in progress for the activity programme in December to be exciting and full of fun. Senior managers spoken to were keen to promote activities that were specifically suited to individuals with memory and cognitive impairment. Arrangements were in place for some staff members to undertake training. Those service users who completed comment cards said that the home ‘always’ or ‘usually’ arranged activities. Service users said that they were able to entertain visitors in the privacy of their bedrooms if they wished to. There was also a quiet room on each unit where service users can sit with their visitors in private. The home will endeavour to meet individuals’ religious and spiritual needs. Special requests are discussed with individuals on admission. Regular visits to the home by representatives from local churches or places of worship are encouraged. The home also has the facility of a prayer room. The staff team support individuals to exercise choice and take control over their lives thus maximising and promoting independence. Wherever possible service users are supported to handle their own finances for as long as they wish to and are able to. It was evident that the home’s staff made service users aware of their entitlement to move in with personal possessions if they wished to. Some rooms seen were personalised with individuals’ personal belongings such as furniture, pictures and mementoes that reflected their personal characters. The home would support service users and their families to access the services of an advocate if they expressed a wish to have one. The home provides a four weekly rotating menu. Breakfast, lunch and an evening meal were on offer along with snacks and drinks available at all times throughout the day and night. The inspector joined service users for lunch on one of the units. There was a choice of meat or vegetarian menu, which consisted of vegetarian sausages, savoury mince, mashed potatoes and vegetables. Dessert served was stewed apples and custard. Lunch was tasty Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 17 and served in clean and pleasant surroundings. Tables were appropriately set with the appropriate cutlery and condiments. Hot and cold drinks were provided. Individuals spoken to said that lunchtime was a sociable occasion and the standard and quality of the food was good. Staff assisted those individuals who needed prompting in a discrete and sensitive manner. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service are able to express their concerns and have access to an effective complaints procedure. Staff are expected to undergo safeguarding of vulnerable adult training, which should ensure that individuals have been appropriately trained and recruited to protect people using the service from any potential harm or abuse. EVIDENCE: A complaints procedure was available to all service users and was included in the statement of purpose and service user’s guide and displayed in the home. Information reflected in the home’s annual quality assurance assessment (AQAA) indicated that the home had not received any complaints since it was opened. It is also pleasing to report that no complainant had contacted the Commission with information concerning a complaint made to the service. Respondents to the Commission’s comment cards said that they knew how to make a complaint and who to speak to if they were not happy. The home has policies and procedures to protect service users from any potential harm or abuse. The manager confirmed that staff had undertaken safeguarding vulnerable adult training at induction, which was ongoing. The home recently notified the Commission of a safeguarding of vulnerable adult incident. The incident was also reported to the local safeguarding vulnerable Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 19 adult team and to the police. Information seen indicated that the home had complied with their procedure. Staff spoken to during the inspection were fully aware of the action to be taken if they suspected or witnessed any incident of abuse to a service user. The home’s recruitment procedure ensures that staff are recruited appropriately and the required criminal record bureau (CRB) checks were undertaken before staff commenced work. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 20 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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which is clean pleasant and hygienic. EVIDENCE: The home was purpose built on three floors in 2007 and is separated into three units. Each of the three units has its own sitting and dining room with a small kitchenette providing tea and coffee making facilities. The layout of the home is suitable for its stated purpose. It was noted that there was a shortage of cupboard space in the kitchenettes and other areas in the building. Handrails and other aids were provided in corridors, bathrooms, and toilets and in service users’ accommodation to maximise their independence. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 21 The inspector toured the home and a random selection of service users’ bedrooms was examined. All bedrooms were single occupancy and have ensuite facilities comprising of toilet, wash hand basins and showers. The building was inspected by the local fire service and environmental health department and complies fully with their requirements. There is an enclosed garden, which provides a safe environment for service users. The grounds looked attractive and were accessible to wheelchair users. Respondents to the Commission’s comment cards said that the home was ‘always’ clean and tidy. The following additional comments were noted: ‘The home is well kept, clean tidy and well organised.’ The premises were clean, hygienic and free from offensive odours on the day of the inspection. The laundry facilities were sited so that so that soiled articles of clothing and infected linen were not carried through areas where food was stored, prepared or eaten. The laundry room was fitted with two driers and three washing machines with the specified programming ability to meet disinfection standards. Infection control measures were fully adhered, to ensure that clean linen was not in contact with soiled linen. The walls and floor in the laundry room were clean and impermeable. Arrangements for the disposal of general and clinical waste were in place, which should ensure that waste is handled appropriately. The inspector was told that those service users who use the hoist on a daily basis did not have individual slings. To comply with the department of health infection control guidance and to minimise the risk of cross infection it is recommended that slings should not be shared between service users and be laundered in the hottest wash cycle allowable to prevent cross infection. It is further recommended that general waste bins in toilet areas should be of the pedal-foot type to prevent the spread of infection. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures people using the service are looked after by staff in sufficient numbers and they have been appropriately trained and recruited to meet their diverse needs. EVIDENCE: At the time of the inspection the home was appropriately staffed to meet the diverse needs of the thirty-six service users that were living in the home on the day of the inspection. The staff team was multi-cultural consisting of qualified nurses, carers, administrative, catering and housekeeping staff. Staff members were observed interacting and communicating appropriately with service users and each other. Service users and relatives who responded to the Commission’s comment cards said that staff were ‘always’ or ‘usually’ available when needed. Two respondents felt that the home was not appropriately staffed and this information was fed- back to the home’s manager to be addressed. Those service users spoken to during the inspection had high praises for staff. The following comments were noted: ‘staff are very kind and good at their jobs.’ I have a good relationship with the staff and they know me very well.’ The following additional comments were noted: ‘Staff are patient and very caring I am so pleased with my decision to put my mum into Castlemead.’ ‘Staff offer care and kindness support and safety.’ Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 23 Staff spoken to during the inspection were knowledgeable about individuals’ needs, which should ensure continuity of care. All staff members were new to the home and had taken up their appointments when the home opened in July 2007. Information reflected in the home’s annual quality assurance assessment (AQAA) indicated that 33 of the care staff had achieved the national vocational qualification (NVQ) in direct care at level 2 or 3. The inspector was told that some staff were registered nurses in their country of origin and were working as senior carers. The recruitment files for five recently appointed staff members were examined. All files contained the required information and complied with the current legislations. The manager confirmed that all staff had undertaken an induction programme, which included fire awareness, health and safety, moving and handling and the protection of vulnerable adult. Some care staff had undertaken training in the safe handling and administration of medication. Further training in the control of substances hazardous to health (COSHH) awareness, emergency first aid, health and safety, dementia awareness and infection control had been planned and evidence of training dates were made available to the inspector during the inspection. However, the home’s training matrix should be developed further to ensure that it clearly reflects the training undertaken by all staff to assist them with the work they are to perform. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 24 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, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has an effective quality assurance system in place to ensure that it is run in the best interests of people using the service. The environment is safe for people and staff because appropriate health and safety practices are carried out. EVIDENCE: The home’s general manager has eighteen years experience working in the care sector and has at least four years experience in a senior management capacity in the managing of a relevant care setting. She holds a health and safety certificate, the registered manager’s awards (RMA) certificate, the national vocational qualification (NVQ) in direct care at level 3 and the D32 and D33 assessor’s award. At the time of the inspection the manager was waiting Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 25 to be registered with the Commission for Social Care Inspection, which was imminent. The care manager’s position was vacant. The general manager has overall responsibility for the home and is supported by the home’s administrator, team leaders, senior carers, carers, housekeeping and domestic staff, kitchen and maintenance staff and the activity organiser. Staff spoken to said that they found the manager approachable and she made them feel valued and empowered them to make decisions. It was noted that staff meetings had taken place and a supervision framework was being introduced. The home has a quality assurance system in place to ensure that the home is run in the best interests of service users. The manager carries out monthly internal audits, which are unannounced at weekends and during the night. Personnel from the organisation also undertake regular audits. Monthly surgeries are held out of hours to give service users, relatives and staff an opportunity to meet the manager privately to discuss any issues of concern. Monthly service users’ meetings and quarterly relatives’ meetings take place. The home aims to send out quarterly service users/relative satisfaction surveys. The results form these surveys would be analysed and a proposed action plan put in place and displayed in the home. The home has a business plan, which is based on a systematic cycle of planning, action, reviewing and reflecting aims and outcomes for service users. The home does not look after service users’ finance. Service users are empowered to look after their finances if they have the capacity to do so and are supported by family members. Each service user has a lockable storage area in their room to store valuables and money. The home has appointed a health and safety person and intends to hold bimonthly health and safety meetings. Information reflected in the annual quality assurance assessment (AQAA) indicated that health and safety records were up to date. The home’s manager checks the fire panel weekly. The home employs a maintenance person, which should ensure that general repairs and maintenance of the building are carried out and equipment used in the home is safe and free from any potential risks. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 26 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations To comply with best practice guidelines any alterations or additions in people using the service care plans should be dated and signed in such a way that the original entry can still be read clearly. To comply with best practice guidelines handwritten entries on the medication administration record sheets for people using the service should be checked by two staff members to minimise any risk of error when transcribing. To comply with best practice guidelines staff should not write or scribble out entries on the medication administration record sheets for people using the service because the sheets are legal documents and can be used in court or in an investigation. To comply with the department of health infection control guidance and to minimise the risk of cross infection people using the service who require hoisting should not have shared slings. DS0000070221.V349665.R01.S.doc Version 5.2 Page 28 2 OP9 3 OP9 4 OP26 Castle Mead Court 5 6 OP26 OP30 To comply with best practice guidelines and to minimise the risk of cross infection general waste bins in toilets and bathrooms should be of the pedal-foot type. The home’s training matrix should be developed further to ensure that it reflects clearly all training undertaken by staff. Castle Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Mead Court DS0000070221.V349665.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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