Inspection on 01/03/04 for Castle View Residential Home

Care Home For Older PeopleCastle View Residential HomeSpring Street Chipping Norton Oxfordshire OX7 5LUUnannounced Inspection1st March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Castle View Residential Home Address Spring Street, Chipping Norton, Oxfordshire, OX7 5LU Email Address Name of registered provider(s)/Company (if applicable) The Orders Of St John Care Trust Name of registered manager (if applicable) Ms Sally Lyon - Proposed Type of registration Care Home No. of places registered (if applicable) 47 Tel No: 01608 642364 Fax No: 01608 645679Category(ies) of registration, with (number of places) Dementia - over 65 years of age (21), Old age, not falling within any other category (47), Physical disability over 65 years of age (4) Registration number H080000331 Date First registered Date of latest registration certificate 1st March 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply? Date of last inspection 6th March 2003 YES NO 24/07/03 If Yes Refer to Part CCastle View Residential HomePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 31st March 2004 06:45 am Ed WatkinsonID Code083686Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Sally Lyon, Manager Designate the time of inspectionCastle View Residential HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementCastle View Residential HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Castle View Residential Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Castle View Residential HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Castle View is a home for older people based close to the centre of the market town of Chipping Norton. The home can accommodate a maximum of 47 individuals. The home provides 24 hour support for all the service users accommodated at the home. The home does not provide nursing care. The Home is now owned and managed by The Orders of St John Care Trust, which is a large charitable organisation that also runs homes in Wiltshire and Lincolnshire. The home was purchased from Oxfordshire County Council in 2002, and there have been significant changes to the structure and organisation of the home since the transfer.Castle View Residential HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection conducted by the NCSC against the National Minimum Standards. This inspection did not cover all 38 Standards, but over the yearly inspection cycle, which includes an announced inspection, all Standards will have been covered. As such, to gain a full picture of the home, the report of the announced inspection undertaken on 24th July 2003 will need to be read. Choice of Home (Standards 1 ­ 6) 3 of the 5 standards assessed were met There was good general information about the Home and the service users and relatives appeared clear about what needs the Home could meet. Contracts were in place and signed by relevant parties. The home has clear admission policies and procedures and are clear about the needs that can be met. This needs to be more clearly defined and the home to be involved in the assessment process in all cases. Health and personal care (Standards 7 ­ 11) 1 of the 4 standards assessed was met Two of the standards were only partly assessed during this inspection. The home has addressed the majority of the requirements and recommendations made in the last inspection. The service user plans are clearly completed and regularly reviewed. The medication systems at the home were generally good, although development is needed with regard to PRN medication, training and certain procedural matters. The home supported service users well during the inspection, and a good knowledge of needs was demonstrated. The home needs to be more proactive in assessing risk, and identifying when risk could be an issue. Daily life and social activities (Standards 12 ­15) 3 of the 3 standards assessed were met The home provides a wide range of activities for the service users, and choice in their daily lives. The home is seen as very much part of the local community of Chipping Norton. Complaints and Protection (Standards 16 ­ 18) 2 of the 2 standards assessed were met The home has robust procedures regarding complaints and protection from abuse and the home has a clear policy promoting the rights of service users.Castle View Residential HomePage 6 Environment (Standards 19 ­ 26) 3 of the 3 standards assessed were met During the inspection the home was seen to cope well with the main dining room being out of use due to redecoration. The areas of the home inspected were odour free and the home generally presented as a pleasant environment. Staffing (Standards 27 ­ 30) 1 of the 2 standards assessed was met There were sufficient care staff and management on duty and the staff on duty were accurately reflected on the staff rota. There was an issue regarding the number of laundry staff on duty with the home having less than the agreed number on duty. The records regarding staff recruitment were well completed and all necessary documentation was seen to be in place. Management and Administration (Standards 31 ­ 38) 1 of the 4 standards assessed was met. All the standards were only partly assessed. Supervision is regularly conducted at the home for all staff, although the supervisors have not received structured training in their role. The home needs to increase the staff awareness of visitors and to challenge individuals who are not recognised.Castle View Residential HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). None.Met (Yes / No)Castle View Residential HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action The Registered Manager must ensure that: · 1 13.2 OP9 · · Medication is only signed for after administration. Processes surrounding PRN medication are improved. The training for staff administering medication includes training from outside the home. April 2004 April 2004 June 20042 312.4.a 18.1.a Section 12 Care Standards Act 2000 13.6OP10 OP27The Registered Manager must ensure that all staff respect the privacy of service users. The Registered Manager must ensure that agreed staffing levels are met at all times. The home must have a manager registered with the NCSC (or the Commission for Social Care Inspection {CSCI} after April 2004). The Registered Manager must ensure that all unrecognised visitors to the home are challenged when seen.4OP31May 20045OP38April 2004Castle View Residential HomePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 OP2 The Registered Manager should ensure that the contracts make reference to relevant legislation. The Registered Manager should ensure that: · 2 OP3 · · The home completes assessments for prospective service users prior to admission. The room allocated for service users meets their assessed needs. Sharing a room does not adversely affect the quality of life for the service users.3OP4The Registered Manager should ensure that the assessment completed clearly states that the home can meet the needs of service users admitted. The Registered Manager should be more proactive in identifying risk to service users and completing appropriate risk assessments. The Registered Manager should ensure that staff conducting supervision have received training to perform the role effectively. The Registered Manager should ensure that there are suitable policies in place regarding drugs and alcohol usage by staff, visitors and service users.4 5OP7 OP366OP37* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Castle View Residential HomePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES YES NO NO YES YES YES NO YES YES NO NO NO YES NO YES 14 0 0 NO NO YES NO X X 01/03/04 7.00 6Castle View Residential HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Castle View Residential HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 400.00 To (£) 493.00Any charges for extras If yes, please state what the extras are:YES Hairdressing, Chiropody, magazines, papers, telephone, holidays, transport for personal use. 3 Standard met?Key findings/Evidence This standard was partly assessed at this inspection.There is a variety of information held within the home that describes the services offered in detail. The `Castle View Home Information Guide is a good, clear document that gives an overview of the services offered and what a service user could expect from the home; this information is centrally held and is shown to all prospective new service users, family members and others who request information regarding the home.Castle View Residential HomePage 13 There is a `Residents Handbook which again provides more detailed information specific to the home, and is comparable to a Service Users Guide. The home also has a Statement of Purpose that meets all the requirements of Schedule 1 of the Care Homes Regulations 2001.Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The home has worked very hard since the last inspection to develop contracts for the service users accommodated at the home. The Inspector sampled a number of service user contracts and found them to be fully completed, and were seen to be relevant and accurate documents. In all cases there was the signature of the service user or representative in place, along with a signature from the representative of the organisation. The organisation still needs to address the inaccurate wording within the contracts as they still make reference to the Registered Homes Act 1984, despite it no longer being the relevant legislation for Care Homes.Castle View Residential HomePage 14 Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? There was a detailed and comprehensive admissions policy held within the home, including the process to be followed regarding an emergency admission. These policies have been recently formulated and are clear documents that reflect and cross reference to the National Minimum Standards for older people and other relevant legislation and best practice guidance. The assessment and associated documentation for two recent admissions to the home were inspected. For one individual there was good, clear information with assessments completed by the home, care management and the hospital discharging the service user. This information had been transferred to the care planning system of the home and the care staff were clear regarding the service users needs. For the other individual there was a care management assessment and a transfer of care assessment, but no assessment completed by the home. The admission was completed rapidly and the service user was placed in a shared room with a lady who has dementia that is having an effect on the lady who was admitted. The manager of the home stated that the situation was not good and the home was waiting for a single room to become vacant so the recently admitted service user could be moved.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. The admissions policy clearly states the need for the home to be satisfied that they can meet the needs of the service user, but this does not translate to the form and there is no section or question that specifically states whether the needs can be met or not prior to admission. Bearing in mind the pressure homes are under to admit service users, and the perceived increased dependency of service users, the home should be very clear and record when it feels that it can or cannot meet the needs of a prospective new admission. This recording should be evidenced and linked to a clear assessment process.Castle View Residential HomePage 15 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The home has recently developed a policy regarding trial periods of residency; the policy is person centred and very clear regarding the processes to follow. There is also a separate policy regarding the admission of service users in an emergency. All the above policies have made reference to the National Minimum Standards and the Care Homes Regulations 2001.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Castle View Residential HomePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. The service user plans in the Standex recording system were recorded as being reviewed on a monthly basis. The home have updated their methods of conducting annual reviews, with the home now being instrumental in the arranging of the reviews on both a six monthly and annual basis. The home invites care management and other relevant parties to all annual reviews. The care manager is responsible for recording the review and sharing with the home. The risk assessments that were available at the home were appropriately completed and stored with individual assessments held within the service user file. However, the home should be more proactive in highlighting risk with regard to service users, and be more instrumental in developing useful, relevant and effective risk assessments.Castle View Residential HomePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence This standard was not assessed at this inspection.X X 0Standard met?Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? This standard was partly assessed at this inspection. The home was still in need of sourcing a thermometer for the medical fridge that displays the maximum and minimum temperatures in a given period. The Inspector witnessed part of a medication round conducted by the care leader on duty. The medication round at Castle View is lengthy and complicated, with a wide variety of medication being administered in both blister packs and direct from source packaging. It was reported that the round could take over two hours to complete. During the round it was noted that medication was signed for prior to the medication being administered. The training with regard to medication is internalised with care leaders receiving instruction from the home manager, without any reference to outside agencies or trainers that could update practice. The processes surrounding the administration of PRN medication was in need of development, as it was on occasion unclear how the PRN dosage would be determined and there was a lack of clarity regarding where to sign for PRN medication administered.Castle View Residential HomePage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 2 Key findings/Evidence Standard met? The preferred and agreed methods of support are clearly noted within the service users care plans. Within the residents handbook the service users are given information regarding how they can expect to be treated by the staff at the home, and about the underpinning ethos of the organisation. The organisation also has a `rights policy that defines the rights that any service user can expect from anybody working in the home. These rights clearly put the service user as the focus of activity at the home. This is supplemented by the `privacy and dignity policy that clearly details the practicalities and mechanics of supporting a service user with dignity and respect. The home has a dedicated surgery, and the GP practices visit every Monday and Tuesday. Generally the staff were seen to work well with the service users, and to have a good awareness and knowledge of their needs and methods of communication. However, on occasion staff were seen to enter service users bedrooms without knocking or announcing their entry, or waiting to seek confirmation from the service user that it was alright to enter their room. All the shared rooms at the home are provided with adequate screening. The home and the organisation are aware that shared rooms can compromise the delivery of good quality care and are working to ensure that all service users in shared rooms share by choice. The processes for receiving mail and making telephone calls promoted service user involvement and privacy.Castle View Residential HomePage 19 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? There is a `death and dying policy within the home. This policy is detailed and contains information regarding the issues that could be presented and gives advice and guidance on how to support a service user including: pain control, contact with GP, involvement of relatives and how to promote comfort. The policy also concerns the procedure to follow in the event of the death of a service user. These policies are supported by information within the individual service user plans that detail wishes after death. There was evidence of the staff at the home being aware of the dependency and needs of the service users, and of being aware when the needs of the service users become nursing and beyond the remit and capability of the staff at the home. The manager stated that the care manager, GP and CPN could all be involved in assessing the need. The changes in needs of the service users are noted within the service user planCastle View Residential HomePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The service users interests and pastimes are recorded within their plans and are encouraged and facilitated by the staff at the home. Within the home there are publicised events such as bingo, reminiscing, sing-along, arts and crafts, dominoes, cards, DVD nights and planned outings. There is also a bar, library, hairdresser and access to a local day centre available for certain service users. Mealtimes were reported to be flexible in timing, and service users stated that they could have their meals in their bedrooms if they so wished. There are appropriate religious services held at the home.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Castle View is seen as being very much part of the local community, with good links with local organisations, associations and groups. The service users use the local facilities within Chipping Norton, and are regularly invited to local functions. Visitors are welcome at any time, with very much an open door policy and an atmosphere of friendliness and community noticeable within the home. Service users can meet with their visitors within their own room or there can be private space made available if necessary.Castle View Residential HomePage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The home values personal choice and encourages and supports autonomy. This was evidenced through policies adopted at the home and also in the individual actions noted by staff during the inspection. During the inspection staff were seen to promote and encourage independence with regard to mobility. Patience was demonstrated by staff and time given to service users to mobilise themselves; this must be commended in what is a pressurised environment where time is a limited resource. There is an advocacy service available for all the service users at the home organised by Age Concern. They visit regularly and hold open meetings and conduct one to one sessions if required. The organisation is aware of the Data Protection Act and its implications. The records were seen to be securely stored with accurate recording being noted.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Castle View Residential HomePage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure, which includes the stages, and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence This standard was partly assessed at this inspection. The complaints procedure now includes details of the NCSC and is appropriately distributed. X X X X X X X 3Standard met?Castle View Residential HomePage 23 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The contract clearly details the rights and responsibilities of the organisation and the service user. There is also a separate rights policy at the home that is person centred and service user focussed in its content and sentiment. There is an advocacy service provided by Age Concern that regularly visits the home and provides a service to all service users who request input. The service users are supported to vote if desired.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence This standard was not assessed at this inspection. Standard met? YES X 0Castle View Residential HomePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Castle View Residential HomePage 25 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. Storage space continues to be an issue at the home, although the home have been creative in their approach and use the hairdressing salon as storage space when it is not in use. On the day of the inspection the main dining area was in the process of being decorated, and as such the other communal areas of the home were being heavily used, which gave the impression of the home being crowded. The Inspector recognises that this was a temporary situation and the home must be commended for coping well with the logistical difficulties created by the redecoration.Castle View Residential HomePage 26 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was partly assessed at this inspection. NO NO YES 25 0 11 0 Standard met? 3 1 240 0 0 11The home is aware of the issues regarding privacy when the service users in double rooms wish to use the sink and promotes privacy as much as possible given the environmental constraints. All service users are now able to use the wash basins within their rooms.Castle View Residential HomePage 27 The home discusses with service users the implications of sharing a room, and choice is given with regard to accepting the room or not. Service users are informed regarding any changes within the home. If there are issues identified with regard to sharing rooms then the individual concerned is prioritised for a single room.Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. The areas of the home seen by the Inspector during the inspection were free from any offensive odours.Castle View Residential HomePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 2Key findings/Evidence This standard was partly assessed at this inspection.The home was meeting its staffing establishment at the time of the inspection with regard to care staff, care leaders, management and cleaning staff. All the staff on duty were familiar with the home and had a good knowledge of their roles and the needs of the service users.Castle View Residential HomePage 29 There was only one laundry assistant on duty at the time of the inspection, and the Inspector was informed that this was a regular occurrence and was seen as sufficient by the home. The staffing establishment states that there should be two laundry staff on duty from 9am until 2pm.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed at this inspection. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. The staff recruitment records sampled by the Inspector were well completed and covered all aspects of required information. All new staff have completed a Criminal Records Bureau (CRB) check prior to working at the home. The home is responsible for ensuring that staff are suitable for work with vulnerable adults, and for the monitoring of staff who are recruited.Castle View Residential HomePage 30 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Castle View Residential HomePage 31 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. The manager of the home is currently applying to be the Registered Manager with the NCSC.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Castle View Residential HomePage 32 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0 X X XCastle View Residential HomePage 33 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. Supervision is in place for all staff including domestic and maintenance staff. Supervision takes place regularly, is recorded and actions are highlighted. The care leaders perform the majority of supervisions and have been given instruction by the manager regarding the methodology and principles underpinning supervision, although they have not received any structured or official training. The organisation has a supervision policy in place. On occasion the manager undertakes the supervision of care staff if there is seen to be a need for close supervision, or if there is an area that the care leaders do not feel sufficiently confident or skilled in supervising.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. The organisation has not developed a corporate policy regarding drugs and alcohol, although there was a policy within the home concerning smoking that was relevant for staff, visitors and service users.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? This standard was partly assessed at this inspection. All fire exits were seen to be clear of obstructions. On arrival at the home at 6.45 am the Inspector was not challenged with regard to the purpose of the visit or why he was on the premises; this was despite being seen by at least two members of staff. After ten minutes the Inspector had to find staff to introduce himself and explain the purpose of the visit.Castle View Residential HomePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateEd WatkinsonSignature SignatureSandra LemonSignatureCastle View Residential HomePage 35 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Castle View Residential HomePage 36 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 1st March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCastle View Residential HomePage 37 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther:NOYou will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these.Castle View Residential HomePage 38 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I .....................................................of ..........................................confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the 1st March 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I ...................................................of ................................................ am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Castle View Residential HomePage 39 - 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!