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Inspection on 26/10/05 for Castlebar Nursing Home

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

This inspection was carried out on 26th October 2005.

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?

This was the first inspection of this home by this inspector so it was more difficult to say what had improved. The requirements met from previous inspection showed that work has been done to monitor complaints better, to record and manage health care needs more effectively and to improve the checks made on staff prior to them starting work at the home. All double rooms have been phased out (apart from one). A lot of work has been done to improve the care planning procedures at the home even though the requirement about this from the last report was not quite met.

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 26th October 2005 10:00 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.V260038.R01.S.doc Version 5.0 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.V260038.R01.S.doc Version 5.0 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) Excelcare Holdings Ms Jayshree Karikari 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.V260038.R01.S.doc Version 5.0 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 30th March 2005 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 runs over thirty homes in England. A director, to whom all the staff are ultimately accountable, directs the service. The day-to-day running of the home is delegated to a care manager, who works full time at the home and who leads a team of staff. Accommodation is provided in 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 located on each floor. Only two of the bedrooms have en-suite facilities. Over a third of places are in shared (double) bedrooms. 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 sited on Sydenham Hill, just off the London south circular road and is accessible by public transport. Local amenities are sited some distance away from the home. Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in October 2005. The inspector met with service users and their relatives, staff, the Registered Manager and the Regional Operations Director. Excelcare has in place a corporate improvement plan that was drawn up in consultation with the Commission that aims to improve all its homes across the country. This plan is mentioned at certain points where relevant throughout this report. The inspector found that there had been significant improvements in many areas within this home and staff are to be commended on the way they are now working with the Commission to make things better for the people living at this home. The responses from service users and their relatives were mixed with some people being very happy and others not. This is to be expected of a home that is working hard to improve things and the next period should concentrate on consultation with service users and their relatives to make sure that their views are being brought into the development of the home. What the service does well: What has improved since the last inspection? Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 6 This was the first inspection of this home by this inspector so it was more difficult to say what had improved. The requirements met from previous inspection showed that work has been done to monitor complaints better, to record and manage health care needs more effectively and to improve the checks made on staff prior to them starting work at the home. All double rooms have been phased out (apart from one). A lot of work has been done to improve the care planning procedures at the home even though the requirement about this from the last report was not quite met. What they could do better: 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. Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 7 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.V260038.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 The information in the Statement of Purpose and Service User Guide is useful and comprehensive meaning that service users and their relatives have a good picture of the home before they decide to move there. A full assessment of a prospective service users’ needs is undertaken before the decision to offer that service user a place is made. This means that service users and their relatives know that they will only be offered a place at this home if staff believe they can meet their needs and offer them effective care and support. EVIDENCE: There were previous requirements that the registered provider must ensure that the statement of purpose and related documents clearly state how it is ensured that service users’ rights - to privacy, dignity, choice and having their changing needs met - are consistently promoted, taking into account the use of the premises and that the registered provider must ensure that the statement of purpose and related documents include a summary of the home’s policy for the sharing of rooms. The home has now changed its policy and all Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 9 rooms are single (discussed further under Standard 23) so these requirements are now made unnecessary. The Registered Manager talked through the process for senior staff’s assessment of a potential service user. The files showed that assessments are made, written and placed on file. Community Care Assessments are received prior to the home’s assessment assessments being made. The Registered Manager was clear about the types of issue that could not be managed within the home such as marked challenging behaviour such as aggression or significant mental health issues other than those related to dementia. This home does not provide intermediate care so Standard 6 is not applicable. Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 The home has carried out significant work on the care planning process but as yet not all service users have in place a full care plan that identifies all areas of need along with action to be taken for staff to meet those needs. Service users health needs are fully met by staff at the home or by bringing in external professionals. Staff respect service users rights to privacy and offer a service that enables service users to maintain personal dignity. EVIDENCE: There was a previous requirement that the registered provider must audit the way the reviews of care plans are conducted and recorded, to ensure that they are holistic and consistent with the stated ethos and values of the organisation. In particular that: - Care plans give a picture of the person as a whole, with emphasis also given to cultural and other identity issues. - Guidelines are developed for staff supporting users with maintenance and developmental goals. Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 11 - Developmental and maintenance objectives are separated from tasks, to enable clearer monitoring, evaluation, review and update of objectives. - Recording includes what is learnt from supporting the service user. - When there are communication issues, (to help establish how the user can best be supported), information is kept around what the person does, what the staff think it means and when it happens. From inspection of files and talking to staff it was clear that a lot of work had been done on thinking about how to improve the care plans. Anew form has been introduced to identify service users’ histories and what they currently like and dislike. This form had not been completed for some service users yet. Some files contained care plans that addressed social and cultural issues and some didn’t. Care plans were strong in the areas of healthcare but less detailed in other issues. Each service users has a separate activities care file/plan discussed under Standard 12. Even though it is acknowledged that care planning has improved a lot since the last inspection there is still further work necessary to ensure that the previous requirement is fully met. (See Requirement 1) Care plans are reviewed monthly as required by there was no evidence that service users or their relatives have been fully involved in the drawing up of their care plan (See Requirement 2) There was a previous requirement that the registered provider must ensure that the home promotes and maintains service users’ health and access to health care services to meet assessed needs. The files have been sorted out since the last inspection and now include information around service users health needs. All service users and their families who were spoken to stated that they felt their healthcare needs were met promptly and effectively. There was a previous recommendation that that the provider considers how, in the absence of external professionals taking part in care plans’ reviews, objectivity and critical reflection can be maintained or enhanced. The Registered Manager stated that service users who fund themselves privately are not reviewed by social services but that all other reviews have taken place or are due to take place with a social worker involved. The files examined showed this to be the case. The home has not yet considered bringing independent advocates or other individuals into service users’ reviews when there is no social worker present, to objectively review performance. The previous recommendation is repeated but reworded. (See Recommendation 1) There was a previous requirement that the registered provider must ensure that the quantities of all prescribed medication carried forward from the previous month are stated on the medication administration record. The Registered Manager stated that all medication is now returned to the chemist at the end of the month so this requirement is not relevant anymore but this standard was not assessed so the requirement is carried over to the next inspection. (See Requirement 3) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 12 There was a previous recommendation that patient information leaflets are obtained from the pharmacy for each dispensed item on the elderly mentally infirm units. The Registered Manager stated that this now occurs but the standard was not assessed so the recommendation is carried forward (See Recommendation 2) There was a previous recommendation that blood monitoring is carried out for all service users on those medication items where this is appropriate, e.g. ferrous sulphate. That staff use these leaflets to familiarise themselves with what each medication is used for and the potential side effects, to effectively monitor service-users’ conditions. The Registered Manager stated that this now occurs but the standard was not assessed so the recommendation is carried forward (See Recommendation 3) There was a previous requirement that the registered provider must re-assess the use of the premises and ensure that they do not impede service users’ right to privacy, dignity and choice being consistently upheld. Again this refers to the use of double rooms in the home, which is now phased out apart from one double room where the service users have actively chosen to continue sharing. Staff were observed to treat service users with respect and dignity and privacy was maintained in one example where staff closed the door to a service users’ room when they went in to undertake some personal care. The inspector talked with several staff who showed awareness of issues around respecting service users and commitment to offering an appropriate service to them. One visitor said that their service user was often dressed in someone else’s clothes when they visited and that their clothes would go missing. This was raised with the Registered Manager who stated they would address the laundry issues. (See Requirement 4) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Service users are not being offered an individual lifestyle at the home that matches their identified preferences and needs. Service users maintain contact with their family and friends as they choose within the home. Visitors are made welcome and relatives are kept informed of developments in the home. There are mixed levels of satisfaction to the food provided at the home from service users and their relatives. While the established menus are varied and appear to offer choices, some individuals find these choices adequate for them and others do not. EVIDENCE: All service users now have separate activities care files, which identify areas that they wish to pursue and monitor any activities undertaken by the activities co-ordinator. The assessments show that some individual activities have been identified for service users but on examining the record of what actually then takes place the files show that the vast majority of activities involve throwing of balls to service users, not what is identified in their assessments as what they would enjoy or what would stimulate them. The inspector discussed with the Registered Manager how all staff need to be involved in activities not just one co-ordinator for sixty-six people. The Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 14 Registered Manager said that other group activities do take place and artwork on the walls, along with the stated weekly programme of groups would evidence that this was the case but on an ongoing basis it is not possible to carry out individual programmes. The inspector observed one service user who was in their bed for a period of six hours with the TV on playing cartoons, which is not acceptable. The inspector also observed some staff talking and interacting with service users in the lounges but other staff who would sit with service users and not talk. Some staff stated that there are not enough staff to manage the basic care and they certainly did not have enough time to do anything else (Staffing levels discussed further under Standard 27) The Registered Manager stated that they would get additional staff on duty when there was a planned event but on the first day of this inspection there was a planned party on the ground floor and there were service users on other floors who could not be brought down to it because there weren’t enough staff on duty to be with them. (See Requirements 5 & 6) The inspector spoke with several relatives and friends who all said that they could visit whenever they wished and that they were made welcome when they did. They said that the Registered Manager kept them informed of developments in the home and that there were now relatives meetings held. General systems in the home appear to support autonomy and choice for example service users can personalise their rooms as they choose. However as discussed under the care planning and activities standards, individual programmes are limited at this home currently, although there has been improvement in these areas. No requirements are made specifically under this standard at this point but the issues around individual choice and how these are met will be fully assessed at the next inspection. The last service user and relatives survey asked questions about food at the home and the answers were mixed. Some relatives spoke to t on the day were happy with the food some weren’t and one said that they feel they have to bring in food that they know the service users likes because they do not get it at the home. Service users spoken to were either happy with the food or had no comment either way. The menus showed that there is a variety of foods and diets on offer at the home, including an African-Caribbean and a vegetarian menu. Further consultation is necessary in this area. (See Requirement 7) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Service users and their relatives know who to complain to and that action will be taken if they raise an issue. Service users are protected from abuse by staff understanding what to do if they suspect abuse and by the procedures in the home for preventing and addressing potential abuse. EVIDENCE: There was a previous requirement that the registered provider must ensure that the complaints’ procedure is effective, that all complaints are recorded and investigated, that staff are able to facilitate complaints and to support users to formalise their concerns, if appropriate. Records showed that this now appears to be the case. New formats have been introduced that record concerns as well as more formal complaints and issues are taken forward from residents’ meetings. Service users families said that they knew how to complain and how to voice any issues that they had. Although work has obviously been done in this area there are now a few different areas where concerns are recorded and there isn’t one comprehensive record of all issues raised with any action taken and outcomes for service users which is noted here but also relates to Standard 33. (See Requirement 8) The Complaints Procedure in the file and as stated in the Service User Guide includes many office addresses for the Commission which would confuse service users and their relatives as to who to complain to and on occasion it still states National Care Standards Commission as opposed to Commission for Social Care Inspection. (See Requirement 9) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 16 Staff were aware of issues around abuse and had received training in this area. It was clear, from discussions with staff, that they were committed to the protection of service users and confident that management would support them if they wanted to raise any concern about care or protection of service users. Relatives said that they had no concerns in this area and felt that any potential abuse issues they raised would be addressed effectively. The home had policies and procedures on dealing with suspected abuse (these were not looked at as part of this inspection). Some service users said that they felt safe at the home, one complained of staff not supporting them appropriately or safely. It was evident from the file that this service user has raised these concerns with staff before and there are some difficulties with communicating and resolving issues in this case. This was discussed with the Registered Manager and although the service user has a social worker who is involved they may benefit from being offered a further independent advocate (See Recommendation 4) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 25 & 26 The building is homely and welcoming. Service users rooms are of adequate size, comfortable and are personalised to meet individual preferences and needs. The building is old and as such a large amount of general decoration and minor maintenance is needed. The toilets and bathrooms are in need of particular work. On the day of the inspection the home was generally clean and hygienic but certain toilets and bathrooms smelt. EVIDENCE: The Registered Manager acknowledged that this is a large, old building and that a lot of work is needed. The organisation is currently undertaking assessments of its buildings and is due to assess this home next. The tour of the building showed that the toilets and bathrooms in the home need to be the priority as they are somewhat institutional in decoration, in need of maintenance and some of them without adequate ventilation, smelt. Alcohol Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 18 wash is not kept in all the toilets/bathrooms as per the latest nursing council advice. (See Requirements 10 & 11 and Recommendation 5) These standards will be assessed further when the home’s assessment has been conducted and a decoration/maintenance programme established. There are communal areas on all floors in addition to service users’ rooms, which are homely. There is an outdoor area that is wheelchair accessible. The dining areas are next to or in the lounge areas on all floors. There had been an occupational therapist’s assessment of the building and the Registered Manager stated that all recommendations from that report had been met. The inspector checked the issues and found this to be the case. All service users and relatives spoken to were happy with their rooms. There was a previous requirement that the registered provider must provide suitable facilities for staff to change. There is a small space in the staff area which has been cleared out and creates a small private, space for staff. Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 It is not possible to fully assess whether the reduced staffing levels are adequate and effective as there has not as yet been a full review conducted of the new rotas. Generally the home operates a comprehensive and robust recruitment procedure which means that service users are protected by ensuring that staff are who they say they are and have the necessary skills and abilities to meet service users’ needs. Staff attend training from several different sources, which means that significant input is made into the staff team from professionally recognised trainers. Individual training plans are not drawn up to ensure that each staff member has developed the particular skills necessary to support these service users. EVIDENCE: Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 20 There was a previous recommendation that that staffing levels are looked at again to ensure that enough carers are available to support all needs of the residents. The Registered Manager said that since the last inspection there had been a reduction in staff and then it had been raised again but not back to the original levels. Some staff said that there are not enough staff on duty to ensure the safety of service users and as mentioned earlier there are not enough staff on duty to engage service users with stimulating individual activities. Some relatives said that they were concerned that there were not enough staff on duty and that they have seen staff on occasion become irritable with each other due to the strain of this. Some relatives said that they were not concerns about the number of staff. The organisation has not reviewed/risk assessed the staffing reduction which took place on May 2005 and must now do this with an emphasis on gathering staff views but also including evidence such as incident/accident reporting. (See Requirement 12) There was a previous requirement that the registered provider must ensure that all statutory checks, to ensure suitability of staff, are conducted and inform the decision to appoint. To this end, existing files must be reviewed and appropriate steps taken, if necessary, to ensure that the checks are consistent with the requirements and the home’s own policy. The inspector examined the recruitment and personnel records of the staff recruited since the last inspection and found that all of the required checks are in place before someone starts employment. References are gained prior to offering a post but some of them are not on headed paper or do not have a company stamp and verbal checking of references are not noted on the files. (See Requirement 13) There was a previous recommendation that when the 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. Although records are made to some extent of an applicant’s interview answers there are no written statements made about the reasons they were considered appointable and the recommendation is repeated. (See Recommendation 6) There was a previous recommendation that that training on promoting residents’ rights, delivered by expert trainers in this field, external to the organisation, is provided for all staff. This has not yet been done. (See Recommendation 7) Excelcare is appointing training officers across the organisation as part of their corporate improvement plan. The home attends the training offered by the Care Home Support Team. Every Wednesday is an internal training/skills sharing day. Different staff have been booked on various training days and the NVQ programme is due to have all non-nursing staff qualified to NVQ Level 2 in Care by December 2005. NVQ achievement will be reviewed towards the end of the financial year at the next inspection. The corporate improvement plan states that all staff will have an individual, core/compulsory training plan in place by December 2005, which will be reviewed at the next inspection. (See Requirements 14 & 15) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The Registered Manager has the qualifications, skills and awareness necessary to be in charge of this home. The management structures above her provide her with adequate support to discharge her responsibilities fully. Although there are some monitoring and quality assurance systems within the home, which have improved since the last inspection, they are not as yet comprehensive or effective enough to ensure that the home is run in the best interests of the service users. The home has in place effective procedures which ensure that money that they hold on service users’ behalf is managed openly and effectively. Generally the health, safety and welfare of service users are protected by the consistent operation of monitoring procedures and systems. EVIDENCE: Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 22 The registered manager of the home, in day-to-day control, has the relevant experience and qualifications in care and management and is a qualified nurse. The organisation has a management structure including senior managers external to the home, the responsible individual and consultants. There had been previous concerns raised at this home about the ability to meet requirements imposed, which appear now to be improved. Although there are some requirements not met from the last inspection there has been significant work done on those requirements and the home and management are working more closely with the Commission to improve standards of care at this home. The home has achieved the Investors In People award, which is a quality assurance tool, which relates to personnel but does not as yet operate a comprehensive externally recognised quality assurance tool throughout all areas of the home. There is a corporate improvement plan in place across all of Excelcare homes that has been developed in conjunction with the Commission which states that a corporate framework is being developed by senior managers that should be in place by the end of January 2006. (See Requirement 16) Action is taken in response to complaints and issues raised but results of action planning is not assessed and recorded. (See Requirement 17) The home has developed certain systems such as the Home Plan and improved the daily handovers to ensure that areas of responsibility are clearly defined and all aspects of the home are reviewed on an ongoing basis. These systems appear to be improving communication and quality but as yet it is too soon to fully assess the impact on care practice so this will be done at the next inspection. There was a previous requirement that the registered provider must review the procedure regarding money held and spent by the provider on behalf of service users and ensure that: - The procedure is adhered to - The reasons for the expenditure are clearly recorded and the consent or decision of the service user is evidenced. What happens to the interest on users’ personal money held by the provider is clearly stated. The records were examined and it seems the policy is now being adhered to. The home does not keep records of what benefits are due to service users from family who manage their benefits on their behalf. This means that no one is monitoring whether service users are receiving all the money they are entitled to. Although the family may be responsible the home had a duty to safeguard service users from potential financial exploitation and as such should keep records of what is due from the family so that any issues can then be identified and addressed (See Requirement 18) The inspector examined all health and safety monitoring and checks and conducted a tour of the building. No health and safety issues were noted that have not been mentioned previously other than the most recent fire system tests, which had not been recorded for five weeks. (See Requirement 19). The current practice for wedging open doors in the home is to put sandbags in front of them. The Registered Manager stated that this was what they were Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 23 told to do by the fire department although she was aware this was not the case in some of Excelcare’s other homes, This practice has not been reviewed for some years. (See Requirement 20) Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 3 3 3 3 2 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 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 Regulation 15 Requirement The registered provider must audit the way the reviews of care plans are conducted and recorded, to ensure that they are holistic and consistent with the stated ethos and values of the organisation. In particular that: - Care plans give a picture of the person as a whole, with emphasis also given to cultural and other identity issues. - Guidelines are developed for staff supporting users with maintenance and developmental goals. - Developmental and maintenance objectives are separated from tasks, to enable clearer monitoring, evaluation, review and update of objectives. - Recording includes what is learnt from supporting the service user. - When there are communication issues, (to help establish how the user can best be supported), information is kept around what the person does, what the staff Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 26 Timescale for action 28/02/05 think it means and when it happens. Previous requirement: Unmet timescale 01/09/05 2 OP7 15 The Registered Manager must ensure that all service users or their relatives are fully involved in drawing up their care plans and that this is evidence on the care plans either by service users (or their representatives) signing the plans or by statements being made on the forms of they are not able to do so. The registered provider must ensure that the quantities of all prescribed medication carried forward from the previous month are stated on the medication administration record. (This is to enable an accurate stock-check to be carried out and to facilitate re-ordering). This is a requirement from a previous inspection that was not assessed at this inspection. 4 OP10 16(2)(f) 12(4)(a) 28/02/06 The Registered Manager must ensure that laundry systems ensure that service users do not have clothing go missing and that they are at all times dressed in their own clothes. The Registered Manager 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. The Registered Manager must ensure that service users who must stay in bed, are not placed in front of a TV playing DS0000007013.V260038.R01.S.doc 28/02/05 3 OP9 13(2) 28/02/05 5 OP12 12(1)(a) 15 18(1)(a) 31/01/06 6 OP12 12(1)(a) 12(4)(a) 31/12/05 Castlebar Nursing Home Version 5.0 Page 27 inappropriate programmes for considerable periods of time. The use of TV must be as part of a considered programme and not the sole form of entertainment or stimulation service users who cannot communicate and move from their bed. 7 OP15 16(2)(i) 24(1) The Registered Manager must ensure that a further comprehensive consultation about the variety and quality of food is undertaken with all service users and their relatives/visitors. Action must be taken and recorded as a result of this consultation. The Registered Manager must ensure that one comprehensive record is maintained of all complaints and concerns, which includes records of any action taken, whether that action was successful and whether the complainant was happy with the outcome. The Registered Manager must ensure that the Complaints Procedure (and guidelines in the Service User Guide) include the up-to-date name of the CSCI and only the address of the relevant CSCI office to which people could complain. The Registered Manager must ensure that a full maintenance and decoration programme is forwarded to the Commission following the upcoming assessment of the building. This programme must prioritise the ventilation, maintenance and decoration of the toilets and bathrooms within the home. DS0000007013.V260038.R01.S.doc 28/02/06 8 OP16OP33 22(24(1) 28/02/06 9 OP16 22 31/03/06 10 OP19 23(2)(a), (b)&(c) 28/02/06 Castlebar Nursing Home Version 5.0 Page 28 11 OP26 16 (2) (k) 30/11/05 The Registered Manager must ensure that all areas of the home are at all times free from offensive odours. The Registered Individuals must ensure that a comprehensive review takes place of the impact of the recent staffing reductions. This review must take account of factual evidence such as accident/incident levels and include the views of staff undertaking the new rotas. This review must be forwarded to the Commission. The Registered Manager must ensure that all efforts are made to ensure the validity of references including receiving references on headed notepaper or with organisational stamps and writing any verbal verifications of references on the applicant’s file. The Registered Individuals must ensure that at least 50 of all non-nursing staff are qualified in NVQ Level 2 or equivalent. The Registered Individuals must ensure that all staff have an individual training programme in place that establishes core/compulsory training and additional training necessary for them to effectively offer care to this service user group. This plan must be reviewed annually. The Registered Individuals must ensure that a comprehensive quality assurance tool is in operation in the home The Registered Manager must DS0000007013.V260038.R01.S.doc 12 OP27 18 (1) (a) 31/12/05 13 OP29 19 (1) (c) 31/12/05 14 OP28 18(1)(c) (i) 31/12/05 15 OP30 1(1)(c)(i) 28/02/06 16 OP33 24 28/03/06 17 OP33 24(1) 28/02/06 Castlebar Nursing Home Version 5.0 Page 29 ensure that the outcomes of all action taken to improve care offered at the home is reviewed and recorded. 18 OP35 13 (6) The Registered Manager must ensure that a record is maintained of all money that is due to service users from their benefits, that is managed by families. If significant issues are noted of service users not receiving money to which they are entitled the home must address this with the relatives or contact the service users’ social worker for a financial review. The Registered Manager must ensure that all weekly fire tests are recorded. The Registered Manager must contact the local fire department to undertake a further assessment of the building and fire practices. 31/01/06 19 OP38 23 (4) 30/11/05 20 OP38 23 (4) 28/02/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The Responsible Individuals must further consider how, in the absence of external professionals taking part in care plans’ reviews, objectivity and critical reflection can be maintained or enhanced. This is a repeat recommendation from a previous inspection. 2 OP9 The Registered Manager must ensure that patient information leaflets are obtained from the pharmacy for DS0000007013.V260038.R01.S.doc Version 5.0 Page 30 Castlebar Nursing Home each dispensed item on the elderly mentally infirm units and that staff use these leaflets to familiarise themselves with what each medication is used for and the potential side effects, to effectively monitor service-users’ conditions. This is a recommendation from a previous inspection that was not assessed at this inspection. 3 OP9 The Registered Manager must ensure that blood monitoring is carried out for all service users on those medication items where this is appropriate, e.g. ferrous sulphate. This is a recommendation from a previous inspection that was not assessed at this inspection. 4 OP18 The Registered Manager should investigate and access and appropriate additional advocate for the identified service user who voices concerns over their care. The Registered Manager should ensure that alcohol wash is kept in all bathrooms and toilets. The Registered Individuals must ensure that training on promoting residents’ rights, delivered by expert trainers in this field, external to the organisation, is provided for all staff. This is a repeat recommendation from a previous inspection. 7 OP29 The Registered Individuals must ensure that when the 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. This is a repeat recommendation from a previous inspection. 5 6 OP26 OP27 Castlebar Nursing Home DS0000007013.V260038.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 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.V260038.R01.S.doc Version 5.0 Page 32 - 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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