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Inspection on 26/07/07 for Castlebar Nursing Home

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

This inspection was carried out on 26th July 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 11:30 26 & 27 July & 3 August 2007 th th rd 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.V342410.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.V342410.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 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.V342410.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 15th February 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.V342410.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.V342410.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days at the home in July 2007 with further information being sent on to the inspector. The inspector met with residents, staff, the new manager and the Regional Operations Manager. The inspector had also spoken with local social services about the home. The inspector toured the building, looked at documents and checked medication stocks. Another home run by this organisation had recently closed and all residents and staff from that home had moved to this home. The inspector spoke with two sets of relatives of residents who had moved to this home and they were happy with the move but three residents who had moved to the home have had to be moved on again by social services as they are not happy with the home. Social services are meeting with the home’s management to discuss and address these individual problems. There had been several complaints made about standards of care at the home recently. The inspector found that some residents and staff are unhappy at the home currently but some continue to say that they are alright. Regardless of the current morale issues and problems that have certainly been caused by the merging of two resident groups and staff teams, the inspector found significant cause for concern during this inspection and many previous requirements remain unmet. The home has a recently appointed new manager which is positive and they stated that they were committed to staying at the home and improving standards. A warning letter was sent to the home about the Commission concerns and an urgent requirement letter was sent regarding medication, home security and fire safety. The home has been included in the Regional Improvement Strategy and the managers must new generate an Improvement Plan to be sent to the Commission. If standards have not significantly improved by the next inspection, enforcement action to ensure compliance will be considered. What the service does well: Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 7 The standards assessed during this inspection showed that: • • • • • Senior staff assess prospective residents’ 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. Most health and safety systems are generally operated as they should. What has improved since the last inspection? • • • • activities have improved (although there is still more work to do) recruitment procedures have improved there is now a permanent manager in post. 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 standards assessed during this inspection showed that: • • residents’ healthcare and personal care needs must be fully met. residents and relatives must be more involved in care planning and reviews. DS0000007013.V342410.R01.S.doc Version 5.2 Page 8 Castlebar Nursing Home • • • • • • medication must be administered effectively. residents’ individual needs must be met by the activities that are on offer. residents must be happy with their meals. a residents’ needs analysis must be undertaken to establish exactly how many staff are required. 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.V342410.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.V342410.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&6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Senior staff assess prospective residents’ needs before they move to the home so that no one is offered a place without the staff team believing they can support someone. Standard 6 is not applicable as this home does not provide intermediate care. 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 guide/statement of purpose as required by the new legislation. This had been done. Staff visit a potential resident and conduct an assessment of their needs before they are offered a place at the home. Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 11 Castlebar Nursing Home DS0000007013.V342410.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 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents’ healthcare and personal care needs are not being fully met which means that they 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. All medication procedures are not effective which means that medication may not be being administered properly. EVIDENCE: 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 Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 13 are accurate. Evidence from the files showed that this is not yet done and there are still problems with how healthcare issues are monitored and managed such as turning charts, fluid charts and wound care records. (See Requirement 1) There was a previous requirement that the Registered Manager must ensure that all care plans and risk assessments are reviewed monthly as required. This is now being done. There was a previous requirement that the Registered Manager must ensure that all entries in the daily notes record the time at which the entry was made. This is not yet being done consistently. (See Requirement 2) There was a previous requirement that 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. This is now being done although records of the annual reviews conducted by staff include no evidence of resident or relative views on their care. (See Requirement 3) There was a previous requirement that the Registered Manager must ensure that all service users have on file a complete inventory of their possession that is kept up-to-date. This is not yet being done. (See Requirement 4) One resident had a bed rail assessment on file but neither they nor their relative had signed to show that they consented to this form of restraint. (See Requirement 5) Resident files on the ground floor are kept in an unlocked cupboard in an unlocked filing cabinet and on several occasions throughout the inspection files were left out on the desk in the main reception area when no staff were around. (See Requirement 6) 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. There was no evidence that this is still being done. There was a previous recommendation that 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. This is not yet done. (See Recommendation 1) There was a previous requirement that the Registered Individual must ensure that staff can understand and communicate effectively with service users. This previous requirement was made because of concerns voiced by relatives and no relatives or residents had this concern during this inspection. Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 14 The inspector examined medication stocks and records on two floors of the home and found cause for concern. There was a previous requirement that the Registered Manager must ensure that medication stock checking systems are effective. This is not yet being done. (See Requirement 7) There was a previous requirement that the Registered Manager must ensure that entries are only made against as required medication when it is taken. This is still occasionally being done. (See Requirement 8) There was a previous requirement that the Registered Manager must ensure that any additional letters used on medication administration charts are clearly defined. This is now done. There were gaps in the recording of medication administered. (See Requirement 9) Changes had been made to residents medications but no records of the GP instructions had been kept to verify that the GP had authorised those changes and the GP does not sign the Doctor’ Book when he attends the service to indicate what treatment he has authorised. (See Requirement 10) There was no record being maintained on one floor of medication that was due to be returned to the chemist and this mediation was not locked in the medication cabinet, just in the clinical room. (See Requirement 11) An open tub of antiseptic cream was found on the toilet in one of the downstairs bathrooms and it did not have any information to identify which resident it was for on it. (See Requirement 12) 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 now been done. Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 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 residents have more chances to take part in daily activities. Residents 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 residents 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 residents to go out by themselves regularly. Residents do not always get what they have chosen to eat and too many of them are unhappy with the food that is on offer. EVIDENCE: Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 16 There were previous requirements 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 and 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. There has been an increase in the number of activities that take place and there are currently two activities co-ordinators in post. The inspector observed the activities and spoke with residents and staff and found that the quality of the activities on offer is not yet acceptable. (See Requirements 13 & 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 have been several complaints from residents recently about the food that the managers were aware of and had been dealing with. The managers acknowledged there is still some way to go to ensure the food offered meets the required standard. (See Requirement 15) Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 17 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 adequate This judgement has been made using available evidence including a visit to this service. Complaints are not being investigated as per organisational policy which means that residents are not being listened to properly and are not having their concerns addressed well enough. 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 residents are being protected from abuse. EVIDENCE: The complaints file showed that some complaint investigations have been ongoing for too long and some of the complaints weren’t recorded on the monthly log. (See Requirement 16) Staff are trained in safeguarding adults issues but given the number of problems noted throughout this report it is not possible to say that the residents at this home are being effectively protected from abuse. Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 18 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 adequate This judgement has been made using available evidence including a visit to this service. The home has now been assessed by an occupational therapist who had no major concerns. The home is due to undergo a major refurbishment in the near future which will hopefully significantly improve the environmental standard. On the day of the inspection the home was clean and hygienic throughout. EVIDENCE: Upon arrival at the home the doors were open and there were no staff in the reception area. The inspector was able to enter the home and move through it without being challenged. (See Requirement 17) Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 19 There was a previous requirement that 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. This had been done and the recommendations are part of the home’s action plan. The Commission and local social services have concerns about the environment particularly on the residential unit but the OT report had not highlighted any concerns with this area. There is extensive refurbishment planned for this home which will hopefully improve the standard of the environment significantly throughout the home. (See Requirement 18 & Recommendation 2) There was a previous requirement that 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. This has been done although the inspector would welcome more work in these areas within the upcoming refurbishment. In certain areas of the home staff notices and memos are on the wall of what should be resident areas. (See Requirement 19) Staff reported that there is no separate changing area for men and women and that the do not have their own lockers. The managers said that they are planning to allow staff to use more space in the basement including a kitchenette. (See Requirement 20) Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 20 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 poor This judgement has been made using available evidence including a visit to this service. There have been several complaints made recently about there not being enough staff on duty and more evidence is needed from the organisation before this can be fully assessed. In addition, more information is required to be able to fully assess if training offered to staff is adequate and effective. Recruitment procedures have improved and generally the home now does enough o make sure that applicants are who they say they are and that they can do their job before they start work at the home. EVIDENCE: Several residents, relatives and staff had concerns about the staffing levels in the home saying that they weren’t high enough and that residents often had to wait for things like showers or to go to the toilet. There had been some days recently when staff had not turned up for their shifts and had not contacted the home to tell them they were not turning up. Staff from the residential floor had on occasion had to be brought down to the nursing floors to fill in while cover could be arranged. Without a full audit of hourly resident needs the Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 21 inspector could not fully assess if there were enough staff on duty to meet the needs of residents at all times. (See Requirements 21 & 22) Staff reported that they had not been able to take their breaks on the day of the inspection and said this regularly happens, especially in the mornings. (See Requirement 23) There has been no team leader in post on the residential unit for several months. (See Requirement 24) There has been no recruitment at this home since the last inspection so the inspector looked at some records from another home as examples of organisational practice. There were several previous requirements about the recruitment procedures all of which were met by this inspection apart from 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. (See Requirement 25) 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. This is now done. During the inspection staff were seen to talk inappropriately in front of residents about their concerns and about other residents’ issues. (See Requirement 26) Due to staff moving over from the home that has recently closed, training records are not up to date and so the inspector couldn’t fully assess if training was adequate. 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. This has not yet been done. (See Requirement 27) Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 22 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 adequate This judgement has been made using available evidence including a visit to this service. There is now a permanent manager in post who has put in an application to be registered with the Commission. 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: Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 23 There was a previous requirement that the Registered Individual must ensure that an application is made to the Commission for someone to be registered as manager of this service. This has now been done. Quality assurance in the home had been gradually improving and an interim manager had put in place systems that do involve asking residents, relatives 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. It was not possible to assess what the new manager will do as she had only been in post for a few weeks prior to this inspection. This area will be fully assessed at the next inspection. There was a previous requirement that the Registered Individuals must ensure that fire doors close as required and are not propped open with chairs. This is no longer being done. There was a previous requirement that the Registered Manager must ensure that weekly tests of the fire system take place as required. Several weekly testes had not been done in the preceding months. (See Requirement 28) There was a previous requirement that 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. This had been done although there had been ongoing problems with the hot water and new parts had been ordered which should resolve them. On a day following the inspection but before this report was written the home ran out of rubber gloves completely. The manager said that this was because staff had not reported that they were running low to the housekeeper. (See Requirement 29) Staff reported that there had been cockroaches on the ground floor recently. Pest control had been called out and treated one room and the managers said they had not been made aware of any cockroaches since then. The inspector didn’t see any cockroaches during the inspection. Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 24 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 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 25 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 OP7 OP8 Regulation 12 (1) & 17 (1) (a) Requirement 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 timescales 28/02/07 & 31/03/07 The Registered Manager must ensure that all entries in the daily notes record the time at which the entry was made. Previous requirement: Unmet timescale 31/03/07 The Registered Manager must ensure that service users and relatives are fully involved in reviews of their care and that 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. Previous requirement: Unmet timescale 30/04/07 The Registered Manager must ensure that all residents or their DS0000007013.V342410.R01.S.doc Timescale for action 30/09/07 2. OP7 OP8 12 (1) & 17 (1) (a) 30/09/07 3. OP7 15 (2) (c) 30/09/07 4. OP7 12 (1) (a) 30/09/07 5. OP7 13 (6) 30/09/07 Castlebar Nursing Home Version 5.2 Page 26 6. 7. OP7 OP9 17 (1) (b) 13 (2) 8. OP9 13 (2) 9. OP9 13 (2) 10. OP9 13 (2) 11. OP9 13 (2) 12. OP9 13 (2) 13. OP12 12(1)(a) ,15 & 18(1)(a) relatives consent to the use of bed rails. The Registered Manager must ensure that all service user information is held securely. The Registered Manager must ensure that medication stock checking systems are effective. Previous requirement: Unmet timescales 27/11/06 & 16/02/07 The Registered Manager must ensure that entries are only made against as required medication when it is taken. Previous requirement: Unmet timescale 16/02/07 The Registered Manager must ensure that all medication, including topic preparations are signed for at point of administration. The Registered Manager must ensure that written GP (or other medical professional) instructions are maintained for all changes to medication regimes and that the GP evidences any treatment or observations when they visit service users. The Registered Manager must ensure that the home keeps a record of all medication that is due to be returned to the chemist and that this medication is stored securely. The Registered Manager must ensure that all topical preparations are prescribed to service users and that they are not left in the bathrooms. 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 DS0000007013.V342410.R01.S.doc 30/09/07 20/08/07 20/08/07 20/08/07 20/08/07 20/08/07 20/08/07 31/10/07 Castlebar Nursing Home Version 5.2 Page 27 14. OP12 12(1)(a) 15 18(1)(a) 15. OP15 16 (2) (i) 16. OP16 22 (3) & (4) 13 (6) 17. OP19 18. OP19 23 (1) & (2) 23 (2) 19. OP19 20. OP19 23 (3) (a) (i) & (ii) engage and stimulate them. Previous requirement: Unmet timescales 28/01/05, 28/02/07 & 31/05/07 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 timescales 28/02/07 & 31/05/07 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: Unmet timescale 28/02/07 The Registered Manager must ensure that all complaints are recorded and investigated as per organisational policy. The Registered Manager must ensure that no one can enter the home without staff knowing they are there. The Registered Individuals must ensure that plans for the refurbishment are sent through to the Commission as a priority. The Registered Manager must 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. The Registered Individuals must ensure that there is a separate changing area for men and women staff and that there are adequate lockable storage DS0000007013.V342410.R01.S.doc 31/10/07 31/10/07 30/09/07 20/08/07 31/10/07 31/10/07 31/10/07 Castlebar Nursing Home Version 5.2 Page 28 21. OP27 18 (1) (a) 22. OP27 18 (1) (a) 23. 24. OP27 OP27 18 (1) (a) 18 (1) (a) 25 OP29 13 (6) 26. OP30 18 (1) (c) (i) 27. OP30 18 (1) (c) (i) & 18 (2) 28. OP38 23 (4) (c) 29. OP38 13 (4) (a) & (c) facilities. The Registered Individuals must 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. The Registered Manager must ensure that staff inform the home with appropriate notice if they are not going to turn up for a shift. The Registered Manager must ensure that all staff are able to take their breaks as planned. The Registered Individual must ensure that someone is recruited to the team leader post on the residential unit. 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: Unmet timescale 31/03/07 The Registered Manager must ensure that staff understand it is not appropriate to discuss other service user issues in front of service users. The Registered Individuals must ensure that following an at least annual appraisal, all staff have in place an individual training and development plan. Previous requirement: Unmet timescales 28/01/06 & 28/02/07 The Registered Manager must ensure that weekly tests of the fire system take place as required. Previous requirement: Unmet timescale 16/02/07 The Registered Manager must ensure that stock control systems are effective and that the home never runs out of DS0000007013.V342410.R01.S.doc 31/08/07 31/08/07 31/08/07 30/11/07 31/08/07 31/08/07 30/11/07 20/08/07 20/08/07 Castlebar Nursing Home Version 5.2 Page 29 supplies of essential things such as rubber gloves. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 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 Individuals should ensure that relevant professional including, occupational therapist, social services and the Commission are consulted prior to drawing up the plans for the refurbishment of the home. 2. OP19 Castlebar Nursing Home DS0000007013.V342410.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 - 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. 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