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Inspection on 24/01/08 for Castlebar Nursing Home

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

This inspection was carried out on 24th January 2008.

CSCI found this care home to be providing an Good service.

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

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

What the care home does well

What has improved since the last inspection?

What the care home could do better:

The home should sustain and expand the improvements brought about by the new activities coordinator and the organisation should implement the redecoration and refurbishment programme recently scheduled for commencement.

CARE HOMES FOR OLDER PEOPLE Castlebar Nursing Home Castlebar 46 Sydenham Hill Sydenham London SE26 6LU Lead Inspector Keith Izzard Unannounced Inspection 24th January 2008 09:45 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.V354191.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.V354191.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 aura.correia@excelcareholdings.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Castlebar Healthcare Ltd Carmen Grech 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.V354191.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 26th July 2007 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.V354191.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.V354191.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection and was completed on one day over a period of, nearly eight hours, by an Inspector and Regulation Manager on 24/01/08. This second unannounced key inspection, for the current inspection year, the last being 26/07/07 was, primarily, focussed on the response made to the substantial number of requirements made previously, and whether they were being complied with, in accordance with the improvement plan submitted by the home. Fortunately the home had fully complied with the requirements made and therefore averted the possibility of enforcement action being taken. The manager, regional manager and staff members are to be commended for the improvement made since the last inspection. The inspection included a complete tour of the premises, examination of individual resident care records and other documentary evidence of health and safety recording. Medication and management systems and documentation were also examined. A detailed pre-inspection questionnaire was submitted, as required to the CSCI by the manager prior to the inspection and the Inspector also referred to records maintained by CSCI since the previous inspection. During this inspection discussions took place with a number of residents and staff members. Seven resident care plans were case tracked in detail, other care records examined and the personnel files of three staff members recently employed were examined in respect of the recruitment practice of the home. Overall, practice was found to be of an improving and good standard. We would like to thank the residents interviewed, the manager, regional manager, nursing and care staff, receptionist, activities coordinator and domestic staff for their helpful and constructive assistance during the inspection. What the service does well: • • Senior staff members assess prospective residents’ needs, including their hobbies and interests, 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. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 7 • • • • There is a pleasant landscaped garden to the rear of the home. Family and friends can visit as they choose. Health and safety systems are operated in accordance with the Regulations and Standards. Care planning records are comprehensive and well maintained. What has improved since the last inspection? • • • Activities are improving (although there is still more work to do, as a new activities coordinator had only recently been appointed) Recruitment procedures have improved There is now a permanent manager in post who has become the Registered Manager for the home and all requirements made at the previous inspection had been complied with. The home has been assessed by professionals to make sure all areas, facilities and equipment are safe for residents • What they could do better: The home should sustain and expand the improvements brought about by the new activities coordinator and the organisation should implement the redecoration and refurbishment programme recently scheduled for commencement. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 8 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.V354191.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.V354191.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): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A full assessment of needs was undertaken before offering a place. Residents would only be offered a place if the manager considered that they could meet the person’s needs and offer effective care and support. EVIDENCE: Standard 3 This Standard was assessed as met at the previous inspection in July 2007 and remains met as senior staff members visit a potential resident to conduct an assessment of their needs before they are offered a place at the home. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 11 Standard 6 This Standard was not assessed on this occasion, as the home does not provide an intermediate care service. Castlebar Nursing Home DS0000007013.V354191.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans examined were comprehensive and well recorded. Health care needs were appropriately attended to and recorded on residents’ care files. Medication was generally well managed. Residents were treated with respect and their dignity maintained. EVIDENCE: Standard 7 At the previous inspection a requirement was made 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. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 13 Evidence from the care files examined at this inspection showed that this is now done for both the nursing and the dementia care units.Healthcare issues are monitored and managed, for example, such as the completion of turning charts, fluid charts and wound care records. There was a previous requirement that the manager must ensure that all entries in the daily notes record the time at which the entry was made. This has improved considerably and is now being done almost consistently. At the previous inspection a requirement was made to ensure that all residents and their relatives are fully involved in developing the resident’s care plan. From the examples seen on all units this is now being complied with and it was noted that all relatives had been written to by the manager in order to encourage this participation. At the previous inspection a requirement was made that all residents have completed for them an inventory of all their personal possessions. This has been complied with as this update was noted on six residents personal files examined at random. In view of a previous requirement that residents, or their relatives must consent to the provision of bedrails this was checked. The relevant records for both the ground floor and first floor were found to have been comprehensively completed ands signed by the resident or their relative, and therefore the requirement made had been complied with. In response to a previous requirement that confidentiality had not been maintained as personal care files had been left unattended we checked both the ground floor units and found all files to be locked away other than those actively being worked on by staff members at the time. This requirement was therefore complied with. Standard 8 Nursing assessments include details of medical history also medication, assessment of pressure areas, falls risk assessments, skin care, moving and handling needs, continence care, communication needs and social preferences. A separate section includes dietary information, and a monthly weight record. The Tissue Viability Nurse regularly visits the home on a monthly basis, or more often, as required. We noted that none of the residents were currently being treated for pressure sores. There was good evidence for appropriate intervention from other health professionals, including the G.P., Chiropodist, Optician, psycho-geriatrician, and dietician. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 14 Standard 9 Medication is stored in the clinical room on the first floor within separate locked metal cupboards for both the storage of internal and external medication. The temperature of the drugs fridge is recorded on a daily basis. A separate lockable controlled drugs cupboard and register were available and two nurses signed for each episode of giving controlled drugs. Medication is administered via a monitored dosage system, and using a medication trolley. Storage was in good order, medication was all in date, and three Medication Administration Records (MAR charts) examined had been well completed. The second floor dementia care unit was similar and found to be apprpriately administering medication to residents and maintaining accurate and complete medication records. It was further noted that topical medication was signed for at the point of administering, stored securely, and written instructions were recorded by the GP in respect of all changes to medication. A returns record for any unused medication was seen, and stored in a locked cupboard in the clinical room and the record is required to be signed by two nurses. Overall, the system for dealing with medication was well organised and safe, furthermore, the six requirements relating to this Standard made at the previous inspection, had all been complied with. Standard 10 Three residents interviewed said that staff members treated them with respect and maintained their dignity at all times. Staff members who were observed by the Inspectors were interacting with residents in a professional and caring manner. All residents seen were appropriately dressed and appeared well groomed and cared for. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was now being focussed on establishing and recording residents interests prior to their admission to the home and improving their involvement in moiré specific areas of activity. Visitors are welcome at anytime, and are able to take part in the life of the home. A varied and nutritious diet is provided for residents. EVIDENCE: Standard 12 Residents are enabled to maintain their personal choice in terms of when they get up and go to bed and what they will do with their time during the day. Meals are served at set times during the day but individual requests for Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 16 variations can be accommodated in order to facilitate outings or appointments for residents going outside of the home. At both the two previous inspections two separate requirements were made to 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.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. It was noted that both the requirements had been responded to positively, following the appointment of a new activities coordinator and the implementation of a programme called SONAS that addressed the implementation of reminiscence sessions for residents. We observed a session taking place on the dementia unit that was favourably received by both residents and the staff involved. Overall, there has been an increase in the number of individual activities that take place and there are currently two activities co-ordinators in post providing a service of fifty hours per week, this is supplemented by involvement from some volunteers. Whilst the appointment of the second activity coordinator had only occurred recently there was sufficient evidence from care/activity records and three residents interviewed that this Standard is now met. Standard 13 Several visitors were in the home during the course of the inspection and it we observed that they were greeted in a courteous and welcoming way. The home has a notice board in the reception area where information is displayed about activities for residents, meetings for residents and relatives and also displayed a copy of the last inspection report. Standard 14 It was apparent that staff did promote some aspects of personal choice. A number of residents interviewed told the inspector that they were able to choose where and how they spent their time, were able to decline the offer to join activities or events if they did not want to attend and were asked about whether they wanted a bath or shower and what they wanted to wear. Standard 15 Lunch was observed on the nursing and dementia units. Tables were nicely laid for lunch with tablecloths, condiments and serviettes, and the daily menu provided. Residents had a choice of two main meals, chosen by them the night before and if neither was suitable then alternatives were provided. Staff were attentive and assisted residents appropriately and discreetly where needed. Four residents who we interviewed stated that the meal was appetising and were usually of a good quality. The pureed meals looked appetising, having Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 17 been separated to identify the individual portions served. This Standard is now met following a previous requirement to ensure choice for residents and that food provided meets the needs of residents. Castlebar Nursing Home DS0000007013.V354191.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. There is a clear complaint process readily available to residents, relatives and involved professionals and all can be confident that complaints will be investigated and acted upon. The home has a Safeguarding Adults policy and procedure. Staff members interviewed had received training and displayed a good understanding in this area. EVIDENCE: Standard 16 The complaints procedure complies with The Care Homes Regulations 2001. Information about the contact details for the CSCI had been updated and there were timescales for staff to follow when investigating concerns. Guidance was provided about the stages that complainants could follow if they were not satisfied with the response provided by the home. No complaints had been received directly by CSCI, although the home had logged three complaints since the previous inspection, all had been dealt with in accordance with the Standard, the procedures required and in a timely way. We were satisfied that all had been addressed and action taken to minimise further occurrence. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 19 Standard 18 Three staff members we interviewed were aware of the procedure for reporting poor practice and abuse and were confident that the manager would act to address any issues they raised. The home has a policy and procedure in place with regard to the protection of vulnerable adults. There was evidence of staff training in this area on the staff personal files looked at and also within ongoing training in this area for staff members in the training matrix for 20087/09. One matter of a protection of vulnerable adults nature had occurred since the previous inspection. The matter had been investigated and resolved to the satisfaction of the local Safeguarding Adults Team within the local authority. The correct procedures had been followed in a timely way with appropriate notifications to the above and the Commission via Regulation 37 notification as required. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and maintained environment. The Home has a satisfactory standard of décor and furnishings, and it provides a reasonably comfortable and homely atmosphere for the residents, but some areas require redecoration and refurbishment that is being planned. The home was clean and hygienic throughout. EVIDENCE: Standard 19 Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 21 This Standard was assessed as almost met at the previous inspection However, requirements were made to ensure that no one enters the home without staff knowing they are there, that plans for the refurbishment are sent through to the Commission as a priority, and ensure that all signage and information on the walls of the home is reviewed to ensure that it is justified and there for the benefit of service users. Also to ensure that there is a separate changing area for men and women staff and that there are adequate lockable storage facilities for staff members. Three areas had been complied with at the time of the inspection and a fourth has been complied with prior to the production of this report. Standard 26 The home was generally clean pleasant and hygienic throughout. Castlebar Nursing Home DS0000007013.V354191.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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home recruits skilled and competent nurses and care workers in suitable numbers to meet the needs of the service users within adequate recruitment procedures. Staff members are trained and competent to do their jobs. EVIDENCE: Standard 27 Four requirements were made following the previous inspection; firstly, to ensure that a full audit is undertaken of all service users’ individual hourly needs in order to establish the actual number of staff required at all times of the day. An audit was submitted to the Commission and the current arrangements for staffing numbers satisfied the Standard. Secondly, to ensure that staff members inform the home with appropriate notice if they are not going to turn up for a shift and that all staff members are able to take their breaks as planned. Also, that someone is recruited to the team leader post on the residential unit. We saw both documentary evidence and verbal confirmation from staff members interviewed, that the latter three requirements had been complied with and, therefore, this Standard is now met. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 23 Standard 28 This Standard was assessed as met at the previous inspection, within the last six months, and remains met. Standard 29 A requirement was made at the previous inspection to ensure that the POVA First check is only used in emergencies and not as a means to start staff at the home as a matter of course. Recruitment practice was examined with reference to staff members more recently appointed and full CRB checks had been received prior to their appointment, therefore this Standard is now met. Standard 30 Two requirements were made at the previous inspection to ensure that staff members understand that it is not appropriate to discuss other service user issues in front of service users. Also to ensure that, at minimum, an annual appraisal takes place and all staff have in place an individual training and development plan. It was noted that the first issue had been addressed at a staff meeting, furthermore two staff members confirmed that they were aware of the need for to maintain the confidentiality of residents at all times. A number of individual staff member training records were examined at random and it was noted that appraisals and individual training plans were well underway to completion. This Standard is now met. Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a registered manager respected by staff members and regarded as approachable by both residents and staff alike. The home ensures that relatives and service users are able to voice their opinions and contribute their views on the running of the home. The home is well maintained, and observes health and safety practices. EVIDENCE: Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 25 Standard 31 This Standard was assessed as met at the previous inspection, when the current manager had only just joined the home. However, since that time the manager has been appointed the Registered Manager of the home following a successful application to the Commission. Furthermore, it is commendable that all thirty-one requirements arising from the previous inspection have either been fully met or are well underway. Communication from the manager with the Commission in respect of notifications and updates on progress has been good. Standard 33 This Standard was assessed as met at the previous inspection, within the last six months, and remains met. Standard 35 This Standard was assessed as met at the previous inspection, within the last six months, and remains met. Standard 38 This Standard was assessed as almost met at the previous inspection, as two requirements were made; firstly, to ensure that weekly tests of the fire system take place as required and also, to ensure that stock control systems are effective and that the home never runs out of supplies of essential things such as rubber gloves. This Standard is now met, as evidence of the weekly checking of call points was seen and a plentiful supply of necessary items was being maintained by the house keeper who stated that the stock control system was very much improved and that no further instances of supplies running out had occurred. A fact substantiated by two other staff members interviewed. Castlebar Nursing Home DS0000007013.V354191.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Castlebar Nursing Home DS0000007013.V354191.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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.V354191.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!