Inspection on 10/05/06 for Castlefort Grange

This inspection was carried out on 10th 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

Castlefort Grange 30/03/10

Castlefort Grange 07/05/09

Castlefort Grange 16/05/07

Castlefort Grange 09/11/06

Castlefort Grange 11/10/05

Castlefort Grange 08/06/05

Castlefort Grange 16/11/04

Castlefort Grange 29/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Castlefort Grange 39 Castlefort Road Walsall Wood Walsall West Midlands WS9 9JL Lead Inspector Maggie Bennett Key Unannounced Inspection 10th May 2006 09:50 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 Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 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. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Castlefort Grange Address 39 Castlefort Road Walsall Wood Walsall West Midlands WS9 9JL 01543 371754 01543 454353 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) Castlefort Grange Care Ltd Mrs Jean Riggs Care Home 23 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (23) of places Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum number of registered beds 23 (twenty-three) at any time No number division between categories except 5 (one) bed may be used for (DE) Dementia or (OP) Older People Requirements as set out in letter to Castlefort Grange Care Ltd. of 27th November 2003 11th October 2005 Date of last inspection Brief Description of the Service: Castlefort Grange is registered to care for 23 older people, 5 of whom may have been diagnosed with dementia. The home is situated in the Walsall Wood area of Walsall and is within easy reach of Brownhills and Walsall. There are shops nearby, but not within walking distance for the majority of service users. The home has undergone major building work to increase its size and provide new rooms. Several of the existing bedrooms have been extended to provide an en suite toilet, the lounge has been extended and a conservatory added. In total there are 17 single rooms and 3 double rooms. There is a separate dining room. The home has a large garden. The home’s current scale of charges ranges from £327.00 to £375.00 per week. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one and a half days, the 10th and 11th May 2006. Prior to the visit a Questionnaire was completed by the Registered Manager of the home. At the time of the inspection there were 18 service users living at Castlefort Grange. Several of the service users were spoken to during the course of the day. In addition three visiting relatives were seen. Discussion also took place with members of staff, the registered manager, deputy manager and the registered person. The care plans of 4 service users were seen in order to “track” their care. A random sample of staff files were also seen in order to check recruitment procedures and training records. A tour took place of the building. It was found that 11 of the statutory requirements made at the last inspection had not been met. A further 15 requirements were made on this occasion. It is unfortunate that the home have been let down by poor care planning, administration and environmental issues. This has resulted in a low rating, which does not reflect the excellent care at the home, the commitment of the staff and the satisfaction of the service users. What the service does well: What has improved since the last inspection? Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 6 The Registered Manager has successfully arranged for staff to take part in appropriate Dementia Care training. Staff feel that this is already of great benefit and is helping them to better understand the needs of their service users with dementia. The care planning system has greatly improved and is now clear and well organised. Since the last inspection there has been more discussion with the service users about social care activities. This has resulted in some requests for outside trips, which are being arranged. Although not yet commenced, the Registered Manager is clearly committed to providing appropriate activities for the service users with dementia and is researching this at present. There have been further improvements to the physical environment of the home. Of particular note is the new floor covering to the lounges and hall areas. This has created a much more pleasant environment. What they could do better: There is now a good system in place for care planning, but this is not being properly utilised. All aspects of the care plan must be completed in order to ensure that individual needs are documented, acted upon and evaluated. During discussion there were a number of examples of staff being aware of service users’ needs, but this clear picture was in their head only and was not reflected in a written document. High priority must be given to improving care planning, as with the present situation there is a danger that the needs and wishes of service users could be missed. It was found at this inspection that the home had been secondarily dispensing medication for one service user. This practice must cease. Both the Complaints Procedure and Adult Protection Procedure need to be updated. These requirements are outstanding from the previous inspection. Seven of the statutory requirements made concern the physical environment. Despite a number of improvements made, there remain some areas of the home which pose hazards to service users. Some of these requirements are outstanding from previous inspections and unless the Registered Person can produce an appropriate Action Plan to meet them, enforcement action will be considered by the Commission. This includes the provision of radiator covers. The laundry remains a problem area, with high temperatures and a possible dust problem. At the time of the inspection the Registered Person was improving the air cooling system. This situation will continue to be monitored. Although staffing levels were found to be adequate at the time of the inspection, insufficient housekeeping staff means that care staff are often covering for laundry, cleaning and cooking duties, thus taking them away from the service users. The Registered Manager and Deputy Manager are frequently covering cooking duties and this could explain why care planning and other administrative tasks are not being completed. It was found that staff files did not contain all the required recruitment documentation and in one case a member of agency staff had been employed without verification of a successful Criminal Records Bureau check or POVA check. The home must develop a training plan and must also ensure that all new staff receive induction training to Skills for Care specifications within 6 weeks of Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 7 appointment to their posts. Copies of training certificates must be available in individual files so that training can be verified. Risk assessments must be carried out on all safe working practice topics. 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. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 8 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 Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 9 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): 3 and 4. The overall outcome for this group of standards is judged to be adequate. All prospective service users receive the benefit of a proper assessment before they are admitted to the home. In some cases this assessment information is not being fully used in the compilation of the care plans. The Registered Manager has arranged for staff to take part in appropriate training, which will enable them to better understand and meet the needs of their service users with dementia. EVIDENCE: The files of 3 recently arrived service users were seen at the inspection. One person was at the home for a respite stay, while the other two were planning to live permanently at Castlefort Grange. Although Standard 2 was not assessed on this occasion, it was disappointing to note that none of the service users had a signed contract on their file. All the service users had a proper assessment on file from their social worker. The home had written a preassessment document, but had not followed this up with their own assessment and had not transferred the information from the social work assessment to Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 10 their care plan. This included important information such as one person having a pressure sore and another being “unaware of potential dangers.” The home must ensure that all those areas listed in Standard 3.3 are covered in the assessment. Since the last inspection the Registered Manager has arranged Aset accredited training in dementia care for her staff. 8 staff have already commenced the training and the remaining staff were due to commence the Friday following the inspection. Staff spoken to during the inspection were finding the training both helpful and challenging. One person said that it had “opened her eyes”. During the inspection staff were observed to be patient and understanding in their care of people with dementia. Standard 6 is not applicable, as Castlefort Grange does not admit service users for intermediate care. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 11 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 and 10. The overall outcome for this group of standards is judged to be poor. The home now has in place a good system for individual care planning, but this needs to be fully utilised in order to ensure that individual needs are documented, acted upon and evaluated. Some shortfalls were noted in medication administration and these need to be addressed in order to fully protect service users. Service users confirm that their privacy is respected at Castlefort Grange. EVIDENCE: The Registered Manager and Deputy Manager have developed a good care planning system, but in the case of the sample of files seen at the inspection, this is not being fully utilised. Information provided in the service users’ assessments could not be found in the care plans. For example, one assessment stated that the service user was incontinent of urine, diabetic, had poor eyesight and was hard of hearing. There was no indication on the person’s care plan as to how these issues were to be addressed. The care plan for a service user on a respite stay was very poor, with minimal information. Care plans contain a risk assessment, but there was no evidence of these Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 12 being regularly reviewed. Some care plans had benefited from more input and in one case it was pleasing to see that the service user’s own words had been used to describe how they wished their care to be given. It is clear that there is the will to improve care planning within the home and some progress has been made. High priority must be given to care planning as the present documents do not provide staff with a clear picture of individual needs and how those needs are to be met on a daily basis. Healthcare needs are documented within the care plans, but as with social care needs, it is not always possible to gain a clear picture from the care plan of the person’s daily needs. Files contained a pressure sore risk assessment, but in several cases these were blank. The home’s own pre assessment form noted that a service user was admitted with a pressure sore, but this was not referred to in the care plan and there were no details of the appropriate intervention. It is clear, however, that the home do seek assistance from healthcare professionals with regard to pressure areas and incontinence. Pressure relieving equipment is provided for several service users. One service user has bed rails and a risk assessment is in place. A food intake chart and weight record chart is on file, but again, these were not completed in all cases. One person is unable to stand on the home’s scales and it is recommended that seated scales be purchased. All service users are registered with a local G.P. Practice and have access to other healthcare services including district nurses, community psychiatric nurses, chiropodist, dentist and optician. Two of the service users spoken to felt confident that the home would seek medical help for them in a timely manner if it were needed. Members of staff spoken to during the inspection were clearly aware of the healthcare needs of individual service users and were able to give examples of how needs were being met. This knowledge needs to be reflected within the care plans. The home has a policy in place for the receipt, recording, storage, handling, administration and disposal of medicines. None of the current service users take charge of their own medication, apart from some creams, which are kept in individual rooms. All service users have a lockable facility in which to keep medication if they wish to self-administer. Appropriate records are kept of all medicines received, administered and leaving the home. The home uses a monitored dosage system for the administration of medication. A sample of the medication records and administration record charts were seen during the inspection. One discrepancy was noted where a tablet had not been administered and there was no explanatory code given. The date of opening of eye drops must be noted on the box. It was found that the home had been secondarily dispensing the medication of one service user from the original containers into a cassette. This practice must cease. If a service user moves into the home and brings medication from home, the medication must be dispensed from the original containers until the Pharmacy supplies the medication in the monitored dosage system. At present the staff at the home are providing 2 signatures on the administration sheet. It is suggested that this could be confusing and that it may be preferable for the person who is Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 13 witnessing the administration of the medication to sign a separate photocopied sheet, which can be kept alongside the original. Since the last inspection the Manager has ensured that staff sign the administration sheet immediately after the medication has been taken. All staff who administer medication have successfully completed accredited medication training. There are currently no appropriate facilities in the home for the storage of controlled drugs and it is recommended that the home make provision for this. There are no service users taking controlled drugs at present. The medication cupboard was found to be sticky in places and in need of cleaning. None of the present service users are sharing a room, the majority being in single rooms. All personal care giving takes place in private. There is a handheld telephone and calls can be made and received in private. Service users wear their own clothes at all times. The induction training package to be used by the home includes instruction on the importance of treating service users with dignity and respect. Although it was observed during the inspection that service users were treated respectfully, it could not be verified that new starters had completed their induction training (see Standard 30). Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 14 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 and 15. The overall outcome for this group of standards is judged to be good. There is a commitment from the Registered Manager and the staff group to provide more frequent social care activities. This needs to be consolidated by making firm arrangements, particularly for outside trips, as some service users (although a minority) state that this is what they want. Care plans do not currently reflect service users wishes with regard to social activities and there is, therefore, a danger that they can be overlooked. Service users confirm that they are able to exercise choice within the home. The meals in the home are of excellent quality and are much enjoyed. EVIDENCE: As part of the case tracking process, care plans were inspected for evidence of appropriate social care activities and whether service users were able to exercise choice in their daily lives. The care planning system provides a section on social care activities, but this was not completed in a number of cases. The social work assessment of a service user on a respite stay indicated that he liked to read the daily paper, liked crosswords and watching snooker on T.V. This information was not on the care plan. It was, however, clear that this service user’s needs were being met in one area as the paper was delivered and given to the service user during the inspection. This is Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 15 another example of care staff being very well aware of service users’ needs, but not transferring this information from their heads to the written document. Discussion has been held with service users to ascertain their wishes with regard to social care activities. A small number of service users have said that they would like to go out to garden centres and for a meal and the Registered Manager confirmed that this is being arranged. One service user spoken to said that not everyone wanted to go out. She said: “I’m happy with a good film.” Another service user, however, did feel that more could be offered. She said: “No – that’s the trouble, there’s too much sitting. That’s what we could do with, something to liven us up. They’re not very talkative, you just sit thinking. I should like to be able to go out. They took me out once.” Staff confirmed that in house activities are arranged, including Music and Movement and visiting entertainers. A representative of the local Church visits each month. The Registered Manager is currently in the process of researching appropriate activities for the service users who have dementia. Service users spoken to confirmed that they were able to see their visitors whenever they wish. Visits take place in any of the communal rooms, or in the service users’ own rooms. The service users spoken to felt that they were able to exercise choice at the home. It was clear during the inspection that all are able to get up and go to bed at a time convenient to them. This includes both the early risers and those who prefer to have a “lie in”. Service users are able to take charge of their own finances if they wish, although none choose to do so at present. The majority request their families to do this. All the service users spoken to said that they enjoyed the food at Castlefort Grange. At present the menu for the main meal of the day does not specify a choice. One service user, however, said that a choice was always available. She said: “If you don’t like something, they will always cook something else.” Another person said: “We can’t grumble at all. We’ve got a good cook.” The cook has been working at the home for several years, knows the service users well and frequently discusses the menu with them. It is recommended that a definite choice is printed on the menu and that preferred choices for lunch are discussed with the service users at breakfast time. Cooked teas and breakfasts are available each day. Ample supplies of food were seen during the inspection, including fresh fruit and vegetables. Fridge and freezer temperatures are taken daily. It is recommended that these are recorded in a bound book. Since the last inspection there has been some work in the kitchen. A fly screen has been provided and kick boards have been fixed. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 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 and 18. The overall outcome for this group of standards is judged to be poor. There is a Complaints Procedure in place, but this is not working, as a current concern expressed by visitors has not been acted upon. The home does have an Adult Protection Procedure, but this needs to be in line with the Department of Health guidance “No Secrets” and the local Social Services Procedure. EVIDENCE: The home does have a Complaints Procedure, but this needs to include stages and timescales for the process. There is also a “concerns” book, which is kept in the hallway and is used mainly by visitors to express concerns. A longstanding concern has been the fact that the front door bell does not work. At the time of the inspection this had still not been dealt with, which must lead visitors and service users wondering if there is any point in making a complaint, as this issue does not seem to have been listened to. Issues with regard to the floor covering at the home have, however, been dealt with and service users say they are pleased with the result. Service users spoken to said that they would know who to complain to and mentioned both the Registered Manager and the Registered Person. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 17 The home’s Adult Protection Policy and Procedure remains unchanged since the last inspection. At the last inspection a statutory requirement was made that this policy be in line with Walsall Social Services Policy and the Department of Health document, “No Secrets”. This has not yet happened. The Registered Manager is clear of her responsibilities under POVA legislation. All staff have taken part in Adult Protection training. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 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, 20, 24, 25 and 26. The overall outcome for this group of standards is judged to be poor. There have been further improvements to the home since the last inspection and the monitoring visit in March 2006. Progress, however, is slow and this is not only frustrating for service users and staff, but there remain some hazards, which put service users at risk. EVIDENCE: The physical environment at Castlefort Grange has been a major concern highlighted at inspections since the refurbishment and extension work was commenced. There is no doubt that there have been considerable improvements to the home over recent years, but progress is slow and a number of areas remain outstanding. A written programme of routine maintenance and renewal of the fabric of the building with projected dates must be forwarded to the Commission. This was not available at the inspection. The grounds are improved and the patio area was being enjoyed Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 19 by service users during the inspection, but there are still areas where there are hazards, which need to be cleared. A risk assessment must be carried out for the garden area. The gate to the garden, which is on a fire exit route, was found to be locked with a padlock. A key in breakable glass must be fitted next to the gate so that it can be opened in the event of an emergency. It was found that some fire doors do not close firmly into the rebates and these must be attended to. There is sufficient communal space in the home for the current group of service users, although if the home were full with 23 there would not be sufficient room for everyone to sit in the dining room at the same time. There is, however, an area off the lounge, which could be used as a dining area, but this is currently used for wheelchair storage. The home is very short of storage space. Furnishings in communal areas are generally of good quality, although some easy chairs need replacing. Floor covering has been replaced and this has created a much more pleasant environment. It is strongly recommended that small tables are provided by easy chairs as currently some service users have nowhere to put their drinks during the day and one service user slipped off a chair during the inspection while she was trying to pick up drink from the floor. At the start of the inspection there was no liquid soap or paper towels in toilets. This was attended to during the day. Water temperatures at outlets accessible to service users, apart from the staff toilet, were found to be below 43 degrees. The staff toilet, which could be accessed by service users, was found to have a dangerously high water temperature and the Registered Person undertook to deal with this in the first instance by making this particular toilet inaccessible to service users. There are sufficient toilets around the home and several bedrooms have an en suite facility. The following individual rooms need attention: Room 8 - radiator covered, but cover not painted. Chair worn on arms. New toilet ground floor - needs liquid soap container fixing to the wall as service users cannot reach the soap from the basin. Room 4 - carpet needs cleaning or replacing. Currently there is no door on the en suite toilet, but a concertina door is to be fitted. Room 5 - double, unoccupied. Bricks and rubbish outside the window. Radiator covered, but cover not painted. Room 6 - carpet needs cleaning or replacing. Bed needs valance. Window should have blinds as the room gets very hot on sunny days. Chest of drawers chipped. Door doesnt close firmly into rebates. Room 7 - no handles on bedside cupboard, marks on chair need cleaning. Very frayed towels. Room 3 - radiator cover fitted, but cover not painted. Shower Room – The Burco boiler stored in here must be removed. Room 2 - no radiator cover. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 20 Room 1 - no radiator cover. Exposed pipes in en suite. Room 9 – storage needed for district nurses dressings and liquid paraffin ointment - all kept on the floor at present. Exposed pipework in en suite. Room 10 – It is difficult for the service user to reach light switch from the bed and this needs adjusting. The radiator needs a cover – it is dangerously hot at 53.70 degrees. It is difficult to adjust the radiator. Lounge - all radiators need covers. Room 14 – The fire door was propped open. An automatic closure device is required. This requirement remains unchanged from the monitoring visit of 3rd March 2006. Room 15 – The wardrobe door has fallen off. The floor slopes - need to address this on risk assessment. Room 11 - divan bed, looks unclean, needs cleaning and needs a valance. Room 16. Floorboards still uneven. Room 17 - still no radiator cover. Bathroom - still storing a hoist in here. Small first floor toilet - no top to tap, so cant access warm water in here. Room 21 - no radiator cover. Room 22 - no radiator cover (currently stored behind the wardrobe). Toilet seat broken in en suite. During the inspection all the residential areas of the home were found to be clean and free of unpleasant odours. One service user said: “I’ve never seen it dirty.” The washing machine has a sluice facility and “dissolvo” bags are used for foul laundry. The problems with the laundry, however, noted at the last inspection, continue. The room is exceptionally hot and rather small and the condensing tumble dryer creates dust. The Registered Person was in the process of improving the air-cooling system in this room at the time of the inspection. The Environmental Health Officer has visited and is due to go again to check compliance with Notices he has issued with regard to the laundry. Some staff feel that the heat in the laundry, combined with the dust, may have caused them and some of the service users to have rashes. Several staff feel that the laundry is now the main problem at the home and are frustrated that it has not yet been resolved. As stated at the last inspection, the laundry door must be locked when the laundry is not in use and clothes cannot be hung from the automatic closure device in this room. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 21 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 and 30. The overall outcome for this group of standards is judged to be adequate. At present care staff are employed in adequate numbers, but the lack of sufficient housekeeping staff (cooking, laundry and cleaning) means that there is a risk of service users’ needs not being met. Staff are achieving well in National Vocational Qualification training, but evidence of this success must be available in individual files. The home’s training plan is constrained by the fact that the Registered Manager does not have a Training Budget. Recruitment checks have not been satisfactory and could place service users at risk. As at the last inspection, induction training for new staff is falling short of the required standard and this may have the potential to place service users at risk from inadequately trained staff. EVIDENCE: At the time of the inspection there were 18 service users living at Castlefort Grange. Staff rotas show that during day-time shifts there are usually 3 care staff on duty. At night there are 2 waking night staff. The Manager’s hours are supernumerary. During the afternoon one of the care staff prepares and serves the tea, leaving 2 carers with the service users. At present there is one service user who needs assistance from 2 carers. As stated at the last inspection, a tea-time cook must be employed so that there are sufficient staff with the service users. The Registered Person states that he has been unable to recruit a suitable person. It is essential that when numbers of service users increase, either a tea-time cook is recruited or an extra member of care staff is Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 22 on shift during this period. The home have also been unable to recruit a cook for weekends and currently either the Manager or Deputy Manager come in to carry out this task. They also cook when the regular cook goes on holiday, thus taking them away from their managerial duties. Domestic staff are employed Monday to Friday. The Registered Person is recommended to reconsider this arrangement, as additional cleaning duties take staff away from their caring duties. The home is confident that 50 of its staff are trained to NVQ2 or equivalent. It is not possible to verify this from staff records, as several files seen did not contain copies of NVQ certificates. There are currently no trainees employed by the home. Four staff files were checked during the inspection. In every case the file contained an application form, but not all areas of the form had been completed. The application form must contain a full employment history, not just details of the last position held. Of the 4 files seen, none contained 2 written references. All files contained copies of satisfactory Criminal Records Bureau checks. Two of the Criminal Records Bureau checks were from a previous employer. The home is reminded that these checks are not portable. One person had been commenced on the basis of a POVA First and there was evidence that the person is supervised, but there was no copy of a risk assessment on file. The home are currently employing a member of staff from an Agency. There were no written records with regard to this person and no evidence of satisfactory CRB and POVA checks. This information was faxed to the home during the course of the inspection. Staff files did not contain all the documentation required by the Care Homes Regulations. There was evidence that staff receive a statement of their terms and conditions. The home have a record of training completed, but no plan of future training. The Registered Manager states that she does not have a training budget and is therefore constrained by only being able to obtain free training. She has been very successful in obtaining a good deal of appropriate training, including mandatory health and safety training, Dementia Care training and Adult Protection training. The home have obtained the Black Country Partnership induction pack, but this was not completed in the 4 files inspected. In only one case was the First Week induction completed and signed within the person’s first week. One person had commenced their induction 11 months after they had started work. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 23 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 and 38. The overall outcome for this group of standards is judged to be adequate. The Registered Manager is qualified and experienced and is committed to providing the service users with a good quality of life. Systems for seeking service users’ and their relatives’ views of the home are being produced and this information will be used to formulate an annual development plan for the home. Service users’ monies are kept securely and their financial interests are safeguarded. There are two service users for whom separate bank or building society accounts should be opened. Health and safety records have improved and it is now possible to verify that the majority of checks are carried out to ensure the health, safety and welfare of service users and staff. Risk assessments must be carried out for all areas of the building (including the garden) and be readily available. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 24 EVIDENCE: The Registered Manager and Deputy Manager have both achieved the Registered Managers’ Award. They are experienced, liked and respected by service users, their relatives and staff. The Registered Person is very “hands on”, spending a great deal of time on the premises and he, also, has a good rapport with the service users. The Registered Manager updates her skills by taking part in periodic training and is currently undertaking the training in Dementia Care. She intends to follow this up with Dementia Care Mapping training. There are clear lines of accountability within the home. As stated in the Staffing Section, the Registered Manager is currently having to undertake too many additional duties, including cooking, which take her away from her managerial duties and this impacts on care planning, administration and the provision of training. Service users’ meetings are held and their views are sought on an informal basis. A “comments” book is available for visitors. Questionnaires have recently been sent out to relatives and the Registered Manager states that questionnaires are also being devised for service users and other stakeholders. The home has not produced an annual development plan. The home looks after the personal allowances for some of the service users and records are kept of all transactions. A sample of the monies and records were seen at the inspection and all were in order. Service users’ monies are accessible to them at all times during the day. In the case of 2 service users, the Registered Person is currently acting as Appointee and neither person has their own bank or building society account. Accounts must be opened in the names of the service users (see Regulation 20(1)(3)). It is recommended that the Registered Person seek the assistance of an Advocate to act on behalf of these 2 service users. According to the home’s training record, the majority of staff have taken part in first aid, fire safety, moving and handling, food hygiene and infection control training. This cannot, however, be verified in all cases as copies of certificates are not available on all staff files. The Registered Manager has compiled a Health and Safety file. This file contained evidence of a fire safety risk assessment, water temperature checks, a gas safety check, engineer’s check and report on works carried out to the lift, maintenance of the hoists, checks on the electrical system and tests for legionella in the water. Fire safety checks are carried out at the required intervals and the fire fighting equipment was last checked and maintained in September 2005. Details of all products used in the home, with an analysis, are available in the office. It is recommended that this is also available in the kitchen. The Registered Manager must develop a written statement of the policy, organisation and Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 25 arrangements for maintaining safe working practice topics within the home. Risk assessments must be carried out for all safe working practice topics and these findings recorded. As stated in Standard 30 (above) the home is not currently providing its new staff with induction training to Skills for Care specifications. Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 X X X 2 1 2 STAFFING Standard No Score 27 2 28 2 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 2 Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement Timescale for action 31/05/06 2. OP7 15(1) 3 OP8 17(1)(a) Schedules 3(p) 3(o) 13(2) 4. OP9 The home must ensure that each service user has a plan of care for daily living, which is based on all the assessment information. The home must ensure that all those details listed in Standard 3.3 are covered in the assessment. Care plans must set out in detail 30/06/06 the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met. They must indicate how issues are to be dealt with, monitored and reviewed and the desired outcome for the service user. (Previous timescales of 31/07/05 and 30/11/05 not met). The home must utilise the 30/06/06 systems it has in place with regard to pressure sore risk assessments and treatment and nutritional screening. There must be no discrepancies 10/05/06 on medication administration records. When a tablet has not DS0000020808.V293652.R01.S.doc Version 5.1 Castlefort Grange Page 28 5. OP9 13(2) 6. OP12 15(1) 7. OP16 17(2) 8. OP18 12(1)(a) 9. OP19 23(2)(b) 10. OP19 23(2)(b) 11. OP19 23(4) been given a code must be entered. Secondary dispensing must not take place. Medication must only be dispensed from original containers. Service users’ interests must be recorded on their care plan and there must be evidence that they are given opportunities for stimulation through leisure and recreational activities in and outside the home. Appropriate records (in a bound book) must be kept of all complaints made and include details of the investigation and any action taken. (Previous timescales of 30/06/05 and 31/10/05 not met). The home must update its Adult Protection Procedure to ensure that it is in line with the Department of Health guidance No Secrets and the Local Authority Procedure. (Previous timescales of 31/07/05, 31/11/05 and 30/04/06 not met). The home must forward to the Commission a written programme of routine maintenance and renewal of the fabric of the building. (Previous timescales of 30/06/05 and 31/03/06 not met). A key to the padlock on the garden gate must be provided in breakable glass next to the gate so that it can be opened in an emergency. The registered person must ensure that all the requirements of the Fire Officer are met. Room 14 must be fitted with an automatic closure device. (Previous timescale of DS0000020808.V293652.R01.S.doc 10/05/06 30/06/06 31/05/06 30/06/06 31/05/06 12/05/06 30/06/06 Castlefort Grange Version 5.1 Page 29 12. 13. OP24 OP25 16(2)(c) 13(4)(a) 14. OP25 13(4) 15. OP26 16(2)(j) 16. OP27 18(1)(a) 17. OP27 18(1)(a) 18. 19. OP29 OP29 Schedule 2 Regs. 7, 9, 19. Care 30/04/06 not met). All fire doors must close firmly into the rebates. All those areas listed as needing attention in individual rooms must be dealt with. The water temperature in the staff toilet must not exceed 43 degrees. It must be checked on a weekly basis and recorded. (Previous timescale of 03/03/06 not met). All pipework and radiators must be guarded. (Previous timescales of 31/07/05, 30/11/05 and 21/04/06 not met). The requirements of the Environmental Health Officer must be met with regard to the laundry. The laundry door must be locked when not in use and clothes must not be hung from the automatic door closure device. (Previous timescales of 31/10/05 and 17/03/06 not met). A cook must be employed during the afternoon shift to prepare the tea-time meal. An extra member of staff must be employed when the cook goes on holiday. This duty should not be undertaken by the manager or deputy manager. (Previous timescales of 31/07/05 and 31/10/05 not met). The home must employ a person to carry out laundry duties (currently this is done by a member of care staff). (Previous requirements of 31/07/05 and 31/10/05 not met). Two written references must be obtained before new staff are appointed. No person may be employed at DS0000020808.V293652.R01.S.doc 30/06/06 10/05/06 30/06/06 12/05/06 30/06/06 30/06/06 10/05/06 10/05/06 Page 30 Castlefort Grange Version 5.1 Standards Act S89 the home until satisfactory CRB and POVA checks have been received. CRB checks are not portable. If staff are employed on the basis of a POVA First check, the home must also carry out a risk assessment and ensure that the person employed is supervised at all times. Staff files must contain all those documents required by Regulation. The home must develop a training plan and forward a copy of this document to the Commission. (Previous timescale of 30/11/05 not met). All new members of staff must receive induction training to Skills for Care specifications within 6 weeks of appointment to their posts. The home must produce an annual development plan, based on a systematic cycle of planning, reflecting aims and outcomes for service users. Service users’ monies must not be paid into the home’s Bank Account. Individual accounts must be opened for those service users who do not have a relative to look after their financial affairs. Copies of certificates to verify training must be available in staff files. The Registered Manager must provide a written statement of the policy, organisation and arrangements for maintaining safe working practices. Risk assessments must be carried out on safe working practice topics and these findings recorded. DS0000020808.V293652.R01.S.doc 20. 21. OP29 OP30 Schedule 2 Regs. 7, 9, 19. 18(1)(c) 30/06/06 30/06/06 22. OP30 18(1)(c) 31/05/06 23. OP33 24 31/07/06 24. OP35 20(1)(3) 30/06/06 25. 26. OP38 OP38 18(1)(c) 12(1) 30/06/06 30/06/06 Castlefort Grange Version 5.1 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP9 Good Practice Recommendations It is strongly recommended that the home purchase a set of seated scales so that all the service users can be regularly weighed. It is recommended that the member of staff witnessing the administration of medication signs a separate photocopied MAR sheet in order to avoid confusion. This sheet is to be kept alongside the original. It is recommended that the home provide suitable facilities for the storage and administration of controlled drugs. It is recommended that the medication cupboard be thoroughly cleaned. It is recommended that leisure activities are discussed with the residents on a regular basis and that a greater variety of activities are offered on a more frequent basis. It is recommended that a definite choice is printed on the menu and that preferred choices for lunch are discussed with the service users at breakfast time. It is recommended that fridge and freezer temperatures are recorded in a bound book. It is recommended that the home seek assistance from the local Advocacy Service for those service users who do not have a relative to assist them with their financial affairs. 3. 4. 5. 6. 7. 8.. OP9 OP9 OP12 OP15 OP15 OP35 Castlefort Grange DS0000020808.V293652.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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