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Inspection on 15/02/07 for Castlebar Nursing Home

Also see our care home review for Castlebar Nursing Home for more information

This inspection was carried out on 15th February 2007.

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

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

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

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Castlebar Nursing Home Castlebar 46 Sydenham Hill Sydenham London SE26 6LU Lead Inspector Lisa Wilde Unannounced Inspection 10:00 15 & 27 February 2007 th th 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 Castlebar Nursing Home DS0000007013.V330129.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. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castlebar Nursing Home Address Castlebar 46 Sydenham Hill Sydenham London SE26 6LU 020 8299 6384 020 8299 6385 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) Castlebar Healthcare Ltd Care Home 74 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0) Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 53 patients, frail, elderly persons aged 60 years and above (female) and 65 years and above (male), and four young disabled persons 21 residents, persons aged 60 years and above, and persons aged 55 years and under 65 years of age suffering from mental disorder 27th November 2006 Date of last inspection Brief Description of the Service: Castlebar is a care home, which provides nursing and residential care for up to sixty-six older people with nursing needs, or support needs due to mental infirmity. The overall stated aim is that of offering care in a home from home setting, meeting individual needs and striving to offer sensitive and conscientious nursing and personal care. The registered provider is Castlebar Healthcare Limited, a company associated to an organisation called ‘Excelcare’, who run over thirty care homes in England. The home is a large nineteenth century building, which has four floors, divided into two main units: one residential and one nursing unit. The nursing care unit is on the ground and first floors and is staffed by qualified nurses and health care assistants. The residential unit, which provides support for mentally infirm service users, is on the second and third floors and is staffed by care assistants. There is a lift. Bathrooms and toilets are on each floor. Four of the bedrooms have en-suite facilities. All bedrooms are single rooms although couples could live together if they chose to. There are shared dining and lounge areas on each of the first three floors. The home has extensive grounds surrounding the property. The front of the premises is paved to allow parking for visitors and staff. The front and back doors are accessible to people in wheelchairs. The home is on Sydenham Hill, just off the London south circular road and is accessible by bus but is some distance from local amenities or a train station. Fees for a place at this home are currently £605.33 for frail nursing if paid for by the local authority, £650 if paid for privately and £515.05 for residential if paid for by the local authority, £550 if paid for privately. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 5 The home makes the reports of the Commission’s inspections available in the reception area. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in February 2007. The inspection was technically unannounced but the inspector let the managers of the service know she was coming a few days beforehand as a meeting had to be arranged with them to discuss how the home was meeting previous requirements made at the last inspection. The inspector spent the first day meeting with service users, staff and managers, touring the building, going through records and checking care plans and medication stocks. The inspector tried to contact relatives to find out what they thought of the service. However it was decided to wait until the next inspection to include relatives’ feedback, given that the last inspection when she had spoken with a number of relatives was only around two months before this inspection. The inspector spoke with professionals who visit the service regularly. It was not possible to fully assess some of the previous requirements as the target timescales for them to be met had not elapsed by the time of this inspection. The inspection started with a meeting to look at the additional Improvement Plan that is in place to make sure that this home improves in the required ways to meet the National Minimum Standards. The inspector found that things have improved since the last inspection but there are still significant areas of concern. What the service does well: The standards assessed during this inspection showed that: • • • • • Service users are given information about the home. Senior staff assess prospective service users’ needs before they move to the home. The home has adequate living and dining areas on each floor and the home is clean and hygienic throughout. There is a pleasant landscaped garden to the rear of the home. Family and friends can visit as they choose. DS0000007013.V330129.R01.S.doc Version 5.2 Page 7 Castlebar Nursing Home • • Most staff hold or are undertaking the NVQ Level 2 or 3 in Care. Most health and safety systems are generally operated as they should. What has improved since the last inspection? • • • • • • • Service users and relatives are more involved in care planning and reviews. care plans more fully describe all areas of support that a service user needs. Activities have improved (although there is still more work to do) Service users are better supported to complain easily. Staffing levels have increased. Recruitment procedures have improved (although there is still more work to do) there are more detailed plans in place to show that service users’ and their relatives’ views are gathered effectively and the home improves in the way that they want. staff now receive enough supervision from senior staff. • What they could do better: The standards assessed during this inspection showed that: • • • • • • • There must be a permanent manager in post. service users’ healthcare and personal care needs must be fully met. Medication must be administered effectively. Staff must be able to communicate well with service users. service users individual needs must be met by the activities that are on offer. all service users must be happy with their meals. the home must be assessed by professionals to make sure all areas, facilities and equipment are safe for service users DS0000007013.V330129.R01.S.doc Version 5.2 Page 8 Castlebar Nursing Home • • • staff must have the skills, awareness and ability to meet all the needs of service users. staff must have an at least annual appraisal of their work. fire systems must be tested as required 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. Castlebar Nursing Home DS0000007013.V330129.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 Castlebar Nursing Home DS0000007013.V330129.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, 2, 3 & 6 Standard 6 is not applicable as the home does not provide interim care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are issued with a service user guide and terms and conditions that tell them about their rights and responsibilities so they know what is expected of them and what they can expect from the home. Senior staff assess prospective service users’ needs before they move to the home so that no one is offered a place without the staff team believing they can support someone. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the breakdown of each service users’ fees is put these in the service user Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 11 guide/statement of purpose as required by the new legislation. This issue is being dealt with by another department within the Commission and advice on this was not available at the time of the draft report being issued. (See Requirement 1) There was a previous requirement that the Registered Individuals must ensure that a representative of the organisation signs all the service users’ terms and conditions. This has now been done for the most part and the few that have not yet been signed are being chased by the home. There was a previous requirement that the Registered Manager must ensure that the Life Reviews are completed as fully as possible (by staff if not the service user or their relatives) for all service users and relevant sections do not state Not Applicable. There have been significant improvements in how these documents are completed. There was a previous recommendation that the Registered Manager should consider ways in which the staff member assessing a potential service users’ needs can be better matched to the service user in terms of gender, ethnicity and culture in an attempt to make the service user more comfortable and more able to discuss their needs. The acting manager said that this has been considered but that currently the home struggles to do anything else as they would need to recruit senior staff of different gender, ethnicity and culture to better meet these needs. This issue will be further assessed at a future inspection. Castlebar Nursing Home DS0000007013.V330129.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 & 11 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A lot of work has been done around care planning and the plans are better than at the last inspection and now describe all areas of support that a service user needs. However they are not being reviewed as required and although service users and relatives are now more involved in the care plans and have had more opportunity to comment on and change them if they wish, they are not as involved as they could be. All this means that service users are not getting the best care they need from all staff at all times. Service users’ healthcare and personal care needs are not being fully met which means that service users may be unhappy or uncomfortable with the support they get from staff or in the worst cases may be being put at risk of harm by the actions or lack of action of staff. Service users now get more regular exercise from staff trained in how to do so. All medication procedures are not effective which means that medication may not be being administered properly. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 13 Service users are cared for when they are dying and there is a programme of training on place to try and make sure that staff do all they can to offer the most effective end of life care. Until all staff are fully trained and adequate organisational policies and procedures are in place end of life care planning currently relies on the skills of senior staff to write detailed care plans. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that care plans are in place for all areas of a service users’ need, that these plans are comprehensive, outline all action necessary to support the service users and are effective. Care must be delivered in accordance with these care plans. Care plans have improved and although they could be made more service user focussed with an emphasis on achieving goals and developing abilities, they do now cover all elements of basic need and action staff should take to meet those needs. There was a previous requirement that the Registered Manager must ensure that all care plans and risk assessments are reviewed monthly as required. One care file examined showed that no care plans had been reviewed in the previous month as required and certain risk assessments had not been reviewed for three months. Staff said there had been one problem with a medication issue for that service user but this should not have prevented all other care plans being reviewed. Another service user’s relative had not been asked to sign the consent for the use of bed rails. (See Requirement 2) There was a previous requirement that the Registered Individuals must ensure that all fluid, nutrition, weight, wound and other healthcare records relating to all relevant service users, are kept contemporaneously, in sufficient detail and are accurate. This area has improved significantly but there were still some problems with accurate recording of all turning charts, food and fluid charts and wound care charts. (See Requirement 3) There had been one incident sent through to the Commission recently which necessitated the inspector checking what time a service user had been found on the floor. The daily records had not been completed with the time of entry so this issue could not be tracked effectively. (See Requirement 4) One service user had not been asked to sign their care plans, possibly because staff were waiting to get the relative to sign them but this service user was fully ale to understand and agree to their care if staff explained the plans to them. (See Requirement 5) There was a previous requirement that the registered provider must ensure that placement reviews take place as planned (including initial 6 week review) Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 14 and that service users and their representatives are involved in those reviews should they so choose. The home is having difficulty involving some social workers in reviews but there is evidence that they are inviting social workers as required and that they are aware of the need to conduct their own reviews at six weeks. Not all service users had complete and up-to-date inventories of their possessions on file. (See Requirement 6) There was a previous requirement that the Registered Individual must employ a full-time suitably qualified, experienced and skilled practitioner to work on the ground and first floors of the home to effectively review all service users’ health and personal care needs and ensure that clear, detailed instructions for staff on how to offer care and support are in place. This had been done and there was evidence that staff understanding and recording had improved on these floors. In addition, there has been a supernumerary senior member of staff in the home given that the interim home manager is not a qualified nurse and this has helped to increase staff support with care planning issues. There was a previous requirement that the Registered Manager must ensure that exercise is offered in accordance with care plans and is recorded and monitored effectively. All exercise must be offered by staff trained in how to do so safely. A member of staff from another home has visited to show staff how to conduct passive exercise with service users and there is now set programme that is followed. Formal training from a physiotherapist has been booked but has not yet occurred. Exercise is currently recorded as an activity in service users’ social care diary whereas it may be more usefully seen as a necessary programme of care. (See Recommendation 1) There was a previous requirement that the Registered Manager must ensure that all staff operate the mechanical hoist in accordance with their training and are clear about the serious dangers involved in operating these hoists alone. The Responsible Individual and interim home manager said that staff have been told not to operate hoists alone but service users reported that staff still do this fairly regularly. (See Requirement 7) There was a previous requirement that the Registered Manager must ensure that risk assessment procedures are used to allow service users to take reasonable risks in order to allow them to make choices and live their lives as the choose, not to try to remove all risks and restrict service users lifestyles. One service user has had their care plans changed to allow them to smoke in their room. There was no other evidence seen of risk assessments being used to restrict service users. There was a previous requirement that the Registered Individual must ensure that staff can understand and communicate effectively with service users. Senior managers said that they were still aware of this issue and were Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 15 attempting to improve staff communication. This issue could not be fully assessed during this inspection. (See Requirement 8) The medication stocks and records were checked. There was a previous requirement that the Registered Manager must ensure that medication stock checking systems are effective but it was found that this was still not the case. (See Requirement 9) There was a previous requirement that the Registered Manager must ensure that any additional letters used on medication administration charts are clearly defined. “F” is still being used regularly without being defined on each occasion. (See Requirement 10) There was a previous requirement that the Registered Manager must ensure that all medication including topical preparations is signed for at the point of administration. This is now being done. In addition, staff are sometimes signing that “as required”` medication is being refused when not required which is against the Commission’s pharmacist advice to leave these entries blank. (See Requirement 11) There was a previous requirement that the Registered Individuals must ensure that staff are trained in and the home operates such systems as the Gold Standard Framework and the Liverpool Care Pathway to fully support someone according to best practice when dying. Staff have been booked on training with the local Care Homes Support Team and there was one care plan on file for one service user who is now receiving palliative care who does not wish to be taken to hospital. The home is not yet operating the formal systems mentioned above but are working with local service to develop in this area. This issue will be further assessed at the next inspection to see if the planned programme of training has taken place and taken effect. There was a previous requirement that the Registered Individuals must ensure that there is an organisational policy drawn up describing the current best practice the home will operate to ensure all service users’ needs are met when they are dieing. This has not yet been done. (See Requirement 12) Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A lot of work has been done in the area of activities since the last inspection and there has been an increase in the amount of group activities that take place so service users have more chances to take part in daily activities. Service users are not however having their individual needs met by the activities that are on offer as there are not enough opportunities for them to take part in things that are not group based and they do not yet have full individual programmes of activity based on what they like to do. Relatives have previously said they can visit the home when they choose and they are always made welcome by staff. Generally service users are only part of the local community if they can get out of the home by themselves; there are occasional trips out of the home but there are not enough staff to support service users to go out by themselves regularly. There has been a recent food survey in the home and some service users are happy with the food they get but others are not. Menus are currently under review and cannot be fully assessed until the next inspection. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 17 EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that individual activities or programmes of development are in place for service users, which are based on their identified interests and needs and are designed to usefully engage and stimulate them. Care plans and social care diaries have now been completed more fully and there has been work done asking service users what they want to do and what they don’t want to do. Some group activities have been changed. While there have been improvements in this area there is further work that must be done as at the moment there is one activities co-ordinator who still has to carry out most of the group and 1:1 activity which is not realistic in a home this size. (See Requirement 13) There was a previous requirement that the Registered Manager must ensure that there is a frequent, regular reminiscence group and/or reminiscence sessions are offered by appropriately trained staff who are supplied with sufficient materials to support service users to remember their early lives. This work must also meet the specific needs of service users from different cultures and ethnicity. As above, there has been improvement in this area as some staff have received training and there had been a room identified that could become a reminiscence lounge but there is not as yet a large stock of materials or a full understanding of what a reminiscence programme should be and how it should be used to support service users with confusion and dementia. (See Requirement 14) There was a previous requirement that the Registered Individual must ensure that service users have a real choice in all their meals and that the food on offer meets the needs of the service users. There has been a recent survey on food and the menu is in the process of being changed to reflect what service users said. One service user said there was still no choice in the evenings. (See Requirement 15) Castlebar Nursing Home DS0000007013.V330129.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are listened to and their complaints are taken seriously and acted upon. More work can be done to monitor and address less formal complaints and concerns. Staff being trained in the issues around protecting adults from abuse and but given the problems evidenced in this report it is not possible to say that service users are being protected from abuse. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that service users are not prevented from making complaints by having to write their complaint down when they want to just tell staff about it and that all complaints are recorded, investigated and monitored effectively. No one told the inspector that this is still the case. There was a previous requirement that the Registered Individuals must ensure that the appropriate agencies are informed in a timely a manner of all reportable incidents at the home. As far as the inspector could tell, this is now being done. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 19 There was some lack of clarity as to whether some incidents had been referred to the local vulnerable adults team or if the home was to continue investigating. The home would benefit from a regular audit and assessment of all incidents reported to external agencies. (See Recommendation 2) Castlebar Nursing Home DS0000007013.V330129.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, 20, 21, 22, 24, & 26 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The communal areas are large enough on all floors but as the home is old and has not been assessed by an occupational therapist, certain areas may not be fit for service users to use safely. Bathrooms and toilets in particular are somewhat institutional and need further decoration to make them homely. There are not enough bathrooms in use on the first floor to meet service users’ needs. On the day of the inspection the home was clean and hygienic throughout. EVIDENCE: There has not been an occupational therapist’s assessment of the entire home and equipment in use. There have been two recent incidents of service users Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 21 being found on or near stairs on the second floor which lead to the dining room or to two other rooms. (See Requirement 16) This is a large, old building and as such many areas of the home now need some work. The bathrooms and toilets in particular are decorated in a manner that is somewhat institutional and bare. (See Requirement 17) Currently one bathroom on the first floor is being used by only one service user due to their particular needs and while this is an attempt to be as supportive as possible this means that ten other service users only have one bathroom which is a higher ratio that allowed by the standards means that and some service users have to be taken downstairs to bath and impacts on how quickly they can get ready for their day. (See Requirement 18) Some service users’ rooms have been decorated to suit their individual tastes but some were quite bare, for example on service user had dementia so couldn’t tell staff what they liked ands their family members were ill so did not visit and their room did not have any additional decoration or personal touches in it. (See Recommendation 3) On the day of the inspection the home was clean and hygienic. Castlebar Nursing Home DS0000007013.V330129.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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels are now adequate on the ground and first floor. Most staff hold or are undertaking the NVQ Level 2 in Care which means that staff should know what they are doing. There are problems with some staff not being able to communicate effectively with service users. Staff receive adequate training in order for them to be able to meet the needs of service users although their training needs have not yet been assessed annually which means they may not be receiving the best training to develop their practice. Recruitment procedures have improved significantly but there are still a few issues to address to make sure that effective checks are in place to make sure staff are who they say they are and can do the job they are hired to do. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 23 EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the planned 6am-11am shift is covered on the ground and first floor. If problems are encountered covering this shift given the early start time then other arrangements must be made to ensure that there are additional staff on the ground and first floors ensure service users’ needs in the morning are met. Staffing levels in the morning have been increased with one additional health care assistant on the first floor from 8am. Staff reported that this has made things easier in the morning. There was a previous requirement that the Registered Individuals must ensure that procedures for covering staff shifts at the home are effective to ensure that there are always the required number of staff on duty at all times. There are procedures on place although as with all care homes, there are problems covering shifts when staff call in sick for shifts at very short notice. There were several previous requirements around recruitment, which could not be assessed as no staff have been recruited for the home since the last inspection. (See Requirements 19 – 21 & Recommendation 4) There was a previous requirement that the Registered Manager must ensure that all staff receive induction and foundation training that is in line with Skills For Care national requirements. Although there is a pack in the organisation that meets the requirements this has not yet been used for any staff at the home. (See Requirement 22) There was a previous requirement that the Registered Individuals must ensure that following an at least annual appraisal, all staff have in place an individual training and development plan. These individual plans must then be brought together into an overall annual training and development plan for the home that identifies what training is required for all staff to ensure the needs of service users and aims of the home are met. The plans for appraisals have been slightly changed and now they are booked throughout the year as opposed to all being done at the same time each year. There will have to be some assessment of individual staff’s training need done by the end of February as the Responsible Individual has to know what training is needed so that she can plan the budget for the year. She felt that training needs could be effectively assessed by the target timescale of end of February although the appraisal programme would now need more time to complete. (See Requirement 23 & Recommendation 5) Castlebar Nursing Home DS0000007013.V330129.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, 36 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is not yet a permanent manager in post who has submitted an application to be registered with the Commission. There are systems in place to find out what service users (and other stakeholders) want and to draw up plans to improve the home based on what they want. At the time of this draft report the final annual development plan had not been finalised. Staff are now supervised regularly and effectively, which means that service users are supported by people who receive enough support and advice from managers. Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 25 Health and safety systems are generally operated as they should be apart from fire system testing which is placing service users at some risk of harm. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the Registered Manager begins the Registered Managers award NVQ. This has changed in that the previous Registered Manager has left the service. The post had been offered to someone new but they had not yet started at the home. (See Requirement 24) There was a previous requirement that the registered provider must ensure that a comprehensive quality assurance system is in operation in the home. This area is gradually improving and the interim manager has put in place systems that do involve asking service users. Relative and other stakeholders what they think and then directly drawing up plans to improve the service based on those views. This policy is in addition to the organisational procedure and the inspector was concerned that this system may lapse after the interim manager moves on given that it is something that each manager would have to put in place on a home-by-home basis but at the moment the requirement is met and will be assessed again at the next inspection. There was a previous requirement that the Registered Individuals must ensure that there is an annual development plan based on the views of service users, their relatives and other stakeholders that shows how the home intends to improve and develop over the forthcoming year. This was done and sent through to the Commission by the final draft of this report. There was a previous requirement that the Registered Manager must ensure that all staff are supervised regularly and effectively. Records showed that this has improved and the plans are to supervise staff once every two months or so. Some fire doors in the home are not closing properly and some are being blocked open by chairs. The weekly tests of the fire system are not taking place as required. (See Requirements 26 & 27) There have been recent problems in the home with the hot water going off in different areas. Parts have been changed but at the last inspection there had also been problems with hot water not being available in certain areas. (See Requirement ) Castlebar Nursing Home DS0000007013.V330129.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 2 Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement The Registered Individuals must ensure that the breakdown of each service users’ fees is put these in the service user guide/statement of purpose as required by the new legislation. Previous requirement with timescale of 31/12/06 not possible to assess fully by the time of the draft report. The Registered Manager must ensure that all care plans and risk assessments are reviewed monthly as required. Previous requirement: Unmet timescale 28/02/07 The Registered Individuals must ensure that all fluid, nutrition, weight, wound and other healthcare records relating to all relevant service users, are kept contemporaneously, in sufficient detail and are accurate. Previous requirement: Unmet timescale 28/02/07 The Registered Manager must ensure that all entries in the daily notes record the time at which the entry was made. DS0000007013.V330129.R01.S.doc Timescale for action 31/03/07 2. OP7 15 31/03/07 3. OP7 OP8 12 (1) & 17 (1) (a) 31/03/07 4. OP7 OP8 12 (1) & 17 (1) (a) 31/03/07 Castlebar Nursing Home Version 5.2 Page 28 5. OP7 OP8 12 (3) 6. OP7 OP8 12 (1) (a) 7. OP8 13 (6) & 18 (1) (c) (i) 8. OP8 OP27 12 (1) & 18 (1) (a) 9. OP9 13 (2) 10. OP9 13 (2) 11. OP9 13 (2) 12. OP11 15 & 18 (1) (c) (i) The Registered Manager must ensure that all service users or their relatives are involved in drawing up their care plans as far as possible and this is evidenced. The Registered Manager must ensure that all service users have on file a complete inventory of their possession that is kept up-to-date. The Registered Manager must ensure that all staff operate the mechanical hoist in accordance with their training and are clear about the serious dangers involved in operating these hoists alone. Previous requirement: Unmet timescale 08/12/06 The Registered Individual must ensure that staff can understand and communicate effectively with service users. Previous requirement with target timescale of 28/02/07 not elapsed by the time of this inspection The Registered Manager must ensure that medication stock checking systems are effective. Previous requirement: Unmet timescale 27/11/06 The Registered Manager must ensure that any additional letters used on medication administration charts are clearly defined. Previous requirement: Unmet timescale 27/11/06 The Registered Manager must ensure that entries are only made against “as required” medication when it is taken. The Registered Individuals must ensure that there is an organisational policy drawn up describing the current best practice the home will operate to DS0000007013.V330129.R01.S.doc 30/04/07 30/04/07 22/02/07 28/02/07 16/02/07 16/02/07 16/02/07 30/04/07 Castlebar Nursing Home Version 5.2 Page 29 13. OP12 12(1)(a) 15 18(1)(a) 14. OP12 12(1)(a) 15 18(1)(a) 15. OP15 16 (2) (i) 16. OP20OP22 OP19 13 (4) (a) & (c) & 23 (1) & (2) ensure all service users’ needs are met when they are dieing. Previous requirement: Unmet timescale 28/02/07 The Registered Individuals must ensure that individual activities or programmes of development are in place for service users, which are based on their identified interests and needs and are designed to usefully engage and stimulate them. Previous requirement: Unmet timescale 28/01/05 & 28/02/07 The Registered Manager must ensure that there is a frequent, regular reminiscence group and/or reminiscence sessions are offered by appropriately trained staff who are supplied with sufficient materials to support service users to remember their early lives. This work must also meet the specific needs of service users from different cultures and ethnicity. Previous requirement: Unmet timescale 28/02/07 The Registered Individual must ensure that service users have a real choice in all their meals and that the food on offer meets the needs of the service users. Previous requirement with target timescale of 28/02/07 not elapsed by the time of this inspection. The Registered Individuals must ensure that qualified occupational therapist with specialist knowledge of the client groups catered for at the home conducts a full assessment of the building, equipment and facilities. This report must be sent to the Commission and any work recommendations made must be actioned as a priority. DS0000007013.V330129.R01.S.doc 31/05/07 31/05/07 28/02/07 30/04/07 Castlebar Nursing Home Version 5.2 Page 30 17. OP21 23 (2) (d) 18. OP21 23 (2) (j) 19. OP29 17 (2) 20. OP29 13 (6) 21. OP29 13 (6) & 17 (2) 22. OP30 18 (1) (c) (i) 23. OP30 OP36 18 (1) (c) (i) & 18 The Registered Individuals must ensure that bathrooms are decorated in a manner that is homely and non-institutional after consulting with service users about their preferences of colour and decorations. The Registered Individuals must ensure that the second bathroom is made good and available for all service users to use. The Registered Individual must ensure that at least two staff interview all applicants and records are kept of all interviewers notes. Previous requirement not able to be assessed due to no staff having been recruited since the last inspection. The Registered Individuals must ensure that the POVAFirst check is only used in emergencies and not as a means to start staff at the home as a matter of course. Previous requirement not able to be assessed due to no staff having been recruited since the last inspection. The Registered Individuals must ensure that potential staff include a full history on their application forms and that any significant gaps are investigated appropriately. Previous requirement not able to be assessed due to no staff having been recruited since the last inspection. The Registered Manager must ensure that all staff receive induction and foundation training that is in line with Skills For Care national requirements. Previous requirement: Unmet timescale 08/12/06 The Registered Individuals must ensure that following an at least DS0000007013.V330129.R01.S.doc 30/04/07 30/04/07 31/03/07 31/03/07 31/03/07 31/03/07 28/02/07 Page 31 Castlebar Nursing Home Version 5.2 (2) 24. OP31 S11 Care Standards Act 23 (4) (c) 25. OP38 26. OP38 23 (4) (c) 27. OP38 13 (4) (a) & (c) annual appraisal, all staff have in place an individual training and development plan. Previous requirement: Unmet timescales 28/01/06 and 28/02/07 The Registered Individual must ensure that an application is made to the Commission for someone to be registered as manager of this service. The Registered Individuals must ensure that fire doors close as required and are not propped open with chairs. The Registered Manager must ensure that weekly tests of the fire system take place as required. The Registered Individuals must ensure that monitoring takes place of how often hot water is unavailable in any area of the home and this monitoring is sent through to the Commission. 31/03/07 31/03/07 16/02/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP18 Good Practice Recommendations The Registered Manager should ensure that exercise programmes are seen as a required part of care rather than just a social activity and are recorded as such. The Registered Manager should ensure that they conduct a monthly evaluation of all incidents that have been copied to external agencies to inform those agencies of the outcomes of any outstanding actions. The Registered Individuals should ensure that should a service user and their family be unable to individualise their own room that some effort is made to do so in order to improve their quality of life. The Registered Individuals must ensure that when the DS0000007013.V330129.R01.S.doc Version 5.2 Page 32 3. OP24 4. OP29 Castlebar Nursing Home 5. OP30 information (given by prospective staff on the application form for a job) or the references do not give enough evidence of the relevant skills or experience necessary for the job, a record is made on the staff file of how the person’s suitability for the position was established. Previous recommendation that could not be assessed at this inspection. That management ensures that training on promoting residents’ rights, delivered by expert trainers in this field, external to the organisation, is provided for all staff. Previous recommendation Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Castlebar Nursing Home DS0000007013.V330129.R01.S.doc Version 5.2 Page 34 - 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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