Inspection on 24/05/06 for Castleford House Nursing Home

This inspection was carried out on 24th May 2006.

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.

Other inspections for this house

Castleford House Nursing Home 10/11/05

Castleford House Nursing Home 15/06/05

Castleford House Nursing Home 18/01/05

Castleford House Nursing Home 13/07/04

Castleford House Nursing Home 19/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Castleford House Nursing Home Castleford Hill Tutshill Nr Chepstow Glos NP6 7LE Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 24th May 2006 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 Castleford House Nursing Home DS0000016398.V296632.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. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castleford House Nursing Home Address Castleford Hill Tutshill Nr Chepstow Glos NP6 7LE 01291 629929 01291 629929 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) Pinnercliff Limited Mrs Madeleine Frances Parsons Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57), Physical disability (57) of places Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: Castleford House is situated on the Gloucestershire/ Gwent border overlooking the town of Chepstow and the River Severn. The house is a large red brick building providing accommodation on three floors, which also have mezzanine levels on these floors. There is a shaft lift and two stair lifts providing access to all levels. In the main, the accommodation is spacious with large landing areas on each floor. There is a large reception, which is favoured as a seating area for many of the residents, plus a lounge, a dining room and a library, which is used as a quiet lounge. There is level access to a patio at the rear of the building and a spacious walled garden and well-laid flowerbeds. Bedroom accommodation consists of twenty-seven single and eight double rooms, with fourteen rooms offering en suite facilities. Two assisted bathrooms are situated on the ground floor and assisted toilets on the first floor. One bathroom and the assisted toilet on the first floor are currently out of use. At the time of inspection the fees are in the range of £490 to £558 for residents who require nursing care and £450 for those who require personal care only. Fees for respite care are £465. All of the above are approximate figures that may be adjusted on an individual basis. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection commenced on one day in May 2006, with the site visit that took place over 6 hours 15 minutes. During this time the inspector spoke to a number of residents, some relatives, staff working in the home, the acting manager of the home and the administrator. Four resident’s files were looked at in detail to include their medication and accident records. Surveys were either completed during interviews with residents or their relatives, or were handed out to relatives/residents during and following the inspection and these results were later collated. What the service does well: What has improved since the last inspection? The recruitment process has improved a great deal since the last inspection and other than a few small points raised such as keeping a record of interviews, most checks and documentation are now in place. New flooring in the dining room has much improved its appearance. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 6 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. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 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 Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 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 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Service users are well informed about the home prior to admission and a full pre-admission assessment is completed. EVIDENCE: Four residents, who had been admitted to the home since the last inspection, were spoken with. There was no sign of Service Users Guides within their rooms although the administrator stated that they should be there. One resident spoken with could recall seeing written information and thought his son was given it. This was confirmed by the administrator who said generally the Service Users Guide was sent /given to the next of kin on or prior to admission. As all of those spoken with had been admitted to the home from hospital or another care environment, they stated that their families had looked around the home and confirmed its suitability. All of the residents spoken with were very happy with the choice of home, although one felt a little isolated as the home no longer had newspapers delivered, he didn’t have a telephone in his room, but thought he may get a mobile phone and was unsure Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 9 of the arrangements for sending and receiving mail. This was fed-back to the acting manager and needs to be resolved. Copies of the Statement of Purpose and Service Users Guide have been seen by the inspector in the past and have been sent to CSCI for information. Surveys received from service users/ their representatives also confirmed that they received enough information about the home prior to admission. Several residents confirmed that a member of staff from the home had visited them in hospital prior to admission and pre-admission assessment forms were seen when care files were examined. Each service user has a written contract, which was confirmed by the administrator in the home and by surveys completed and returned, although one said they didn’t know. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are set out in the individual plan of care. Service users health care needs are fully met. Service users 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. EVIDENCE: Care files of four service users were reviewed during the inspection. Their initial assessments were seen and it was clear from these how care plans were formulated to ensure care reflected the current needs of these service users who have either been interviewed or were seen receiving care. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 11 For example one who had had a pressure sore had a great deal of information on wound care and monitoring of the wound to include photographs. Care planning was set out accordingly and as needs have changed these have been adjusted. In each case seen pressure sore risk assessments are completed and reviewed as frequently as required and pressure- relieving equipment is identified in the care files. In most instances there was evidence that care files have been reviewed with relatives of the resident. Other risk assessments were also seen to include moving and handling and nutritional risk assessments but in a few instances these had not been signed and dated. Daily records were seen but again these were not always in good order. Some had entries written on the back of unlined forms, one entry was crossed out, one left gaps and some were signed with initials rather than full signatures. Staff must be mindful that these are legal documents and must be completed clearly and accurately. Records showed and residents confirmed input from other professionals such as regular doctors visits, the chiropodist, the dentist and the optician. Wound care advice was also sought. The home currently has six residents who suffer from diabetes and are insulin dependent needing close monitoring. All have relevant care planning and records of monitoring in place. Several have been unstable and this has improved since admission, but one is currently in hospital to be stabilised. There were some concerns from staff prior to the inspection, as to the levels of care required by these residents. One spoken with still has concerns that when one qualified nurse is on-duty alone, ensuring that all receive their medication at the correct time is sometimes difficult. It had been advised that staff received updates on diabetes care from a diabetic specialist nurse but this has not yet been arranged. One regulation 37 report received, regarding an incident with a service user was followed up at inspection with the acting manager and service user and appears to have been resolved. It was all fully recorded in the care file. The medication charts of those service users whose care records were reviewed, were seen and discussed. Good records were maintained and regular medication audits are completed both by senior staff in the home and the dispensing pharmacy. Medications are administered and stored in accordance with policies and procedures. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 12 There are eight double rooms in the home and fourteen rooms with en suite facilities. A married couple who are very happy with their accommodation currently occupy one double room and some double rooms are currently single occupancy. One resident spoken with had shared a room initially but now occupies the room alone and said that sharing had not caused any problems. The nurse in charge during the afternoon was observed showing relatives of a prospective resident around the home and explaining to them about the double rooms. Staff were observed knocking on doors prior to entering rooms and ensuring that privacy was maintained when carrying out personal care tasks. Residents who wished to go to the toilet were assisted sensitively. One resident who had accidentally spilt a drink was discreetly taken from the lounge into the nearby bathroom to have clothing changed. Staff managed this situation with sensitivity. A relative and friend of one service user confirmed how happy they were with the care observed and received in comparison with other homes’ they had experienced. They said the atmosphere in the home was relaxed and happy and from the resident’s behaviour and appearance they felt secure in the knowledge that he was well looked after. The resident himself confirmed this. Another relative phoned the inspector following the inspection and also confirmed her satisfaction of the home and how well she felt her mother had settled. Her only negative comment was that it was quite difficult transferring her mother in a wheelchair in the lift when they visited and felt the lift was quite cramped. She did however say that she had never heard her mother comment on any difficulties experienced by the staff when they used it with residents and other than previous problems with the lift breaking down (it has since been repaired) there had been no other reports of difficulties experienced. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 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 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users generally find the lifestyle experienced in the home offers as stimulating an atmosphere as they wish, to meet their recreational interests and needs. Service users maintain contact with family, friends, representatives and the local community as they wish and are helped to exercise choice and control over their lives. Service users receive a wholesome, appealing, balanced diet but alternative arrangements need to be found for those residents who require assistance at mealtimes. EVIDENCE: An activities organiser visits the home several days a week to organise visitors to the home such as music and movement sessions and entertainers, social events such as birthday and special event celebrations and for one to one activities. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 14 One resident spoken with stated that they played cards and crib together and also spoke of all the entertainers, ‘at least 5’ over the Christmas period. A relative spoken with also mentioned that they had requested a small table, which was promptly produced and they have since played dominoes with their mother. There were no activities taking place during the morning of the inspection but a music and movement session was planned later. One relative did say how nice it was to see that when staff were not busy with some tasks they sat and talked to residents. A programme of activities for June was displayed on the notice board and it was reported that a trip to a local garden centre had been proposed. Birthday presents and cards were also in evidence in preparation for several birthdays later in the week and every resident has a birthday cake to celebrate their birthday. One couple visited were enjoying Prime Ministers question time on the television and another gentleman said he was quite happy to stay in his room and watch television or listen to his music. Several were looking forward to being able to walk in the gardens when the weather became warmer. The administrator did confirm that there were currently problems getting papers delivered to the home, with the change of owner of the local paper shop but they will be looking to resolve this. The hairdresser visits weekly and there is a hairdressing salon on the top floor of the home. Service users were observed, and confirmed that they are able to receive their visitors in private and where possible links with the community are maintained. One resident spoken with said how he goes out regularly with his family and it was noted in another’s records of outings taken with his wife. Breakfast, which is quite a leisurely occasion, was still being served on arrival and some residents enjoy a cooked breakfast every day. Choices are offered at every meal and individual preferences noted. Everyone spoken with and observed enjoy the meals provided and confirmed that they are always of a good quality. Residents have the choice of where they eat their meals and one in particular said he had chosen to eat in his room, which staff confirmed was no problem. With the increasing frailty of a large number of the residents, many more now require assistance or at least prompting with each meal. Separate rooms have been identified for those who eat independently and those who require assistance but the latter is now extremely crowded and Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 15 space at the table does not allow for staff to sit beside residents to help them. It is not acceptable for staff to stand and feed a resident or to feed more than one resident at a time. Alternative arrangements are currently being explored to overcome this problem. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Staff have recently received training on Protection of Vulnerable Adults (POVA) and all those spoken with who have attended so far found it very enlightening and greatly raised their awareness. The home always reports any complaints or incidents to CSCI and since the last inspection there have been a number of incidents reported, several of which were related to staff whistle blowing and allegations of abuse. These have all been dealt with in accordance with their Abuse Policy and one member of staff was recently reported to POVA. However, it is advised that their policy is reviewed in accordance with the Adults at Risk Policy and Alerters guide to ensure that when an allegation of abuse is made, The Adults Protection Unit and where appropriate the police are the first point of referral before any investigation is initiated by the home. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 17 Residents spoken with confirmed that they knew what to do if they had any concerns or complaints and were confident that these would be dealt with effectively. One stated ‘he knew where the matrons office was and would call in there’. Staff also stated that if they had any concerns they go to see the acting manager or administrator and where possible problems are resolved. Several staff made particular reference to the acting manager and how supportive she was, listening to staff and dealing with their concerns, ‘she is always there for us’. It was clear from speaking with staff and looking at statements written that staff have some awareness of what to do if they see anything that concerns them. Castleford House Nursing Home DS0000016398.V296632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Residents in the home are provided with a clean and comfortable environment to live in with a satisfactory standard of décor. A planned and rolling maintenance programme would significantly improve the appearance overall appearance of the home. EVIDENCE: Although there is evidence of some maintenance having been carried out, staff spoken with appeared to be unaware of when the maintenance man is due to work at the home and how much input they can expect. Several staff stated how they continually report jobs that need doing. Some even said that they had resorted to doing certain things themselves rather than wait indefinitely. ‘Jobs to be completed’ are entered into a book for the maintenance man to refer to and sign when completed. Copies of the last months work were Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 19 requested and it would appear from this that there are now no outstanding jobs, but there are only dates recorded when the job is identified not when the jobs were actually completed. Since the last inspection new flooring has been fitted in the dining room, which greatly enhances the appearance of the room and is so much easier for the domestic staff to keep clean. A tour of the home took place but not every room was visited on this occasion. Those rooms seen were clean, in good decorative order and comfortably furnished. Despite constant cleaning the upper floor landing carpets were stained in places and also edges were becoming loose and could be dangerous. One room noted was odorous, probably because a full urinal had been left there. Staff were asked to remove this. Another room had a stained carpet because of a resident’s ‘accident’, but the cleaning staff, were aware of and were attending to this. After months of only one assisted bathroom in use, the second bath was replaced. However, because the handset had broken it had again been out of action since early May, which staff said had been quite difficult. It was reported that the maintenance man was due in the day after the inspection and would hopefully be able to fit the new handset. Also because some plumbing work was in hand in the upper floor assisted toilet, this had been locked until the work was completed. One resident spoken with on this floor now has to walk further along the corridor to get to a toilet. Generally the standard of furnishings in the home is very good but in a number of rooms there is still no armchair for either the resident or their visitors to sit on other than a commode chair which from an infection control and a comfort point of view is not satisfactory. This has been raised on a number of occasions but the proprietors do not see the necessity for providing separate chairs. An electrical fault had occurred in the kitchen during the morning, which caused some problems keeping the food hot for lunch, but it had been reported to the owner of the home who was reportedly dealing with it. Residents and relatives spoken to said how clean everywhere was. One resident related how his room was hoovered every morning and his washbasin cleaned. He was also very impressed with the laundry service, saying ‘if you leave dirty clothes out at 5 am, they are collected and brought back within a couple of hours. The laundry assistant was seen late morning taking newly laundered clothes back to the rooms, and the housekeeper usually makes the early morning collection. Castleford House Nursing Home DS0000016398.V296632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are usually met by the numbers and skill mix of staff and are in safe hands at all times, although maintenance of staffing levels is difficult at times, resulting in staff volunteering to work excessive hours to cover shifts. Service users are not always supported and protected fully by the homes’ recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: A qualified nurse and five care staff were on duty during the morning and a qualified nurse and five care staff on the late shift on the day of inspection. A further qualified agency nurse was on early morning until 11 am as the acting manager was not on-duty until 9 am. A new RGN on his first days’ induction was also present during the morning. Staff related that they work long hours; most of them on-duty were working a 12 hour shift; one stated she often works 60 hours a week, but volunteers do so to cover staff Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 21 shortages. Residents and relatives also stated that ‘staff are always on the go’. As there have been reported episodes in the past where certain members of staff became impatient with certain residents it is very important that staff are not allowed to get over tired by working excessive hours. Those members of staff have since left the home. It was reported later that the home plans to recruit some more care staff in the near future. Several key-workers were identified and spoken with about the residents they were responsible for. All showed an excellent knowledge about these residents, their conditions, their identified needs and how these are met, and also spoke of the relationships that are built up with the relatives. Residents and relatives confirmed this. Each of the carers spoken with had undertaken or were currently doing NVQ training. All were very enthusiastic about this and some were contemplating going on to complete nurse training. A total of 6 staff have completed NVQ training and a 7th has just commenced. The home has not quite achieved 50 of the staff with NVQ 2 as yet and will work towards achieving this. All spoke enthusiastically about the recent POVA training and also said they had access to lots of training, both mandatory and on specialist subjects such as continence. A list of individual training records was provided by the home. Staff files of all staff appointed since the last inspection were seen. All had an application form completed with a full career history and/or CV. All had two written references, confirmation of mental and physical fitness, proof of identity to include a photograph and POVA First had been completed on all until CRB disclosure had been returned. Unfortunately as the home does not have access to e-mail, there is no written confirmation of POVA First other than a record made by the administrator as to when it was phoned through to the home and by whom. A written confirmation should be requested of the umbrella body. There is no record of interview kept at present, which is advisable for Equal Opportunities and no written induction programme to confirm what induction each member of staff has undertaken. Copies of training certificates were seen in staff files and some supervision records. Staff spoken with confirmed that they had all received appraisals before the manager went on maternity leave, but none had received supervision since. It is recommended practice that all staff receive 6 formal supervisions per year. Castleford House Nursing Home DS0000016398.V296632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. 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 her responsibilities fully. The home is run in the best interests of service users and their financial interests are safeguarded with minor adjustments being made to the keeping of records. The health, safety and welfare of service users are promoted and protected provided an ongoing maintenance programme is in place. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager of the home is currently on Maternity leave and plans to return in September 2006. However, she keeps in close contact with the home and does return at times to carry out some of the clinical audits that regularly take place. In the meantime the acting manager assisted by the administrator continue to run the home very ably. It was observed that the home continues to be run in an efficient manner, with good clinical care and staff reported that they feel confident to be able to report any concerns to the acting manager or the administrator and know that they will be dealt with. Although they have not had any staff meetings since the manager went on maternity leave, all the staff on-duty meet at each shift change for full handovers. These were observed and are used, in addition to books as means of communicating to the staff. Residents and relatives also confirmed that there is an ‘open door’ policy and the manager is always available if they need to discuss anything with her. The home has not distributed any satisfaction surveys to residents/their relatives for some time. This needs to be carried out at least annually in order to capture the views of the residents and their families, identify shortfalls and develop an action plan to rectify these. The manager carries out clinical practice audits fairly regularly. Results of these audits were seen and include medication, care plan, infection control and accident audits. These identify any shortfalls and in the case of accident audits, patterns and appropriate action is then taken. It was reported that the home now only manages the finances of one service user, the responsibility for this otherwise being with the resident themselves or their family/representative. A record was seen of the accounts for this one service user. The administrator does hold ‘pocket money’ for a number of residents at the request of themselves or their families and a record is kept of any financial transaction undertaken. Whilst a receipt is generally given for any money handed in this is not always so and it was recommended that this be done to ensure that all transactions can be audited. Records were seen to confirm that regular servicing and maintenance of equipment is carried out. The nurse in charge tests the fire alarms weekly and emergency lighting is tested monthly. A record of hot water temperature monitoring was also seen. Recent correspondence for the Fire Safety Officer indicated that the fire risk assessment has just been updated. This was not seen but was later reported to be with the owner of the home. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 24 A report from the Environmental Health Officer also indicated a recent visit where several issues were raised for attention. Confirmation is requested, that these have been completed. It was reported on the day of inspection that there was a fault with some of the electrical equipment in the kitchen, to include the heated trolley and extractor fan, resulting in difficulty keeping the food hot at lunch-time. This was reported to the owner and was said to have been in working order again the following day. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 23 Requirement Ensure that all parts of the home are kept well maintained (Timescale of 10/01/06 not met in full). All equipment is to be serviced regularly and requirements from EHO visit are met to ensure the health, safety and welfare of the service users. Ensure that there is adequate and suitable dining space provided separate from the service users’ private accommodation. Ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of the service users. Ensure that all relevant checks and records are completed and satisfactory prior to the appointment of a new member of staff. A system must be maintained to review and improve the quality of care provided in the home DS0000016398.V296632.R01.S.doc Timescale for action 30/06/06 2. OP38 23 30/06/06 3 OP23 15 30/06/06 4 OP27 18 30/06/06 5 OP29 19 30/06/06 6 OP33 24 24/11/06 Castleford House Nursing Home Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 Refer to Standard OP7 OP27 OP35 OP36 Good Practice Recommendations All records must be clear, signed and dated. Aim for 50 of care staff to be qualified to NVQ level 2. Collect a receipt for all service users money handed in for safekeeping. All care staff to receive formal supervision at least 6 times a year. Castleford House Nursing Home DS0000016398.V296632.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Castleford House Nursing Home DS0000016398.V296632.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. 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