Inspection on 11/10/05 for Castlefort Grange

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 10/05/06

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 Announced Inspection 11th October 2005 08:30 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.V256446.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Castlefort Grange Address 39 Castlefort Road Walsall Wood Walsall West Midlands WS9 9JL 01543 371754 01543 374114 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.V256446.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Requirements as set out in letter to Castlefort Grange Care Ltd. of 27th November 2003 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 8th June 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 residents. The building 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. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday between 8.30 a.m. and 7.00 p.m. Prior to the inspection a Questionnaire was completed by the Registered Manager and returned to the Commission. Several residents and some of their relatives completed anonymous Comment Cards, which were also forwarded to the Commission. During the inspection the care plans of 7 residents were seen, along with accompanying documentation. The medication and accompanying records were inspected. Several staff files were seen in order to check sound recruitment procedures and relevant training. A tour took place of the building. Several residents were spoken to during the course of the day and one relative was seen. Discussion also took place with staff members, the manager and deputy manager and the Registered Person. Other documents were inspected in order to check compliance with health and safety requirements. Following the last inspection, in June 2005, 23 statutory requirements were made. 3 of those requirements were found to have been met in full, with several partly met. 13 further statutory requirements were made at this inspection. 13 of the total number of requirements concern the physical environment of the home. What the service does well: What has improved since the last inspection? There was evidence at this inspection that new residents are not admitted to the home until they have received the benefit of a full assessment. The medication was found to be stored in good order and shelves have now been provided with a more hygienic surface. There has been some progress on the development of required policies and procedures, although some work remains to be done. The garden is very much improved since the last inspection and Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 6 residents were able to enjoy the fresh air in the summer months. Although there remain shortfalls in staff training, the Registered Manager has secured places for Adult Protection Training. She has also held discussions with a local training organisation and hopes that this will lead to improved staff training, particularly in induction for new starters and dementia care. 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. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Prospective residents receive a full assessment prior to moving to the home. The home does not admit any new resident until they feel that they can meet the person’s needs. Further training is needed to ensure that all care staff can meet the needs of their residents with dementia. EVIDENCE: The files of four recently admitted residents were seen at the inspection. In all cases there was evidence that the residents had received a full assessment prior to their admission to the home. This information had been used to form the basis of the residents’ individual plans of care (see Standard 7). The Registered Manager has been unable to access suitable training in dementia care. This training is urgently needed, as the home cares for five people with dementia. The manager has recently held discussions with a local training organisation and hopes that this training can be provided in the near future. As at the last 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 residents for intermediate care. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 9 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. Residents’ personal and healthcare needs are assessed, but the system used for care planning is disorganised and does not ensure that individual needs are documented, acted upon and evaluated. The systems for the administration of medication are generally good, but the home must ensure that residents are observed when taking medication. Residents confirm that their privacy is respected at the home. EVIDENCE: The care plans of 6 residents were seen during the inspection. These were difficult to follow, primarily because of poor organisation of the files. Assessment information is currently kept separately from the care plans. It is suggested that each resident should have their own individual file, which contains all the required documentation. Files should have an index and different areas be separated by dividers. Care plans need clearer details on how the assessed needs of the individual residents will be met. It should be possible to cross-reference any important issues in daily records to care plans in order to check that plans are being Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 10 followed. For example, one resident was described as having a tendency to “wander” and also exhibiting some episodes of aggressive behaviour. There was nothing in the care plans to describe how this behaviour was to be addressed. Care plans do contain a risk assessment, but these need more detail in relation to the risk of falls. Currently the home use a generic falls risk assessment and it is suggested that this format could be used for individuals. Residents’ care plans are reviewed on a monthly basis. The home must ensure that where residents are on respite stays, a formal review is held before any decision is reached to admit the resident to long-term care. Where possible, care plans should be signed by the resident. Healthcare needs are identified on the care plans, but as with social care needs, health needs must be clearly identified and plans put in place to meet those needs. It was noted that one resident was being visited regularly by the District Nurse to treat a pressure sore (which the resident had before she was admitted to the home). There was no pressure sore risk assessment on file and no indication of the controls in place to minimise the risk. Although the resident was receiving full care and attention and specialist equipment was in place, this was not clearly documented. Another resident was stated as having an aneurysm, but there were no clear instructions on the care plan as to what this meant and what symptoms the resident might experience. A further resident was noted as having a very poor appetite and being reluctant to take fluids. Again, a care plan must be in place for this problem. In addition a diet and fluid intake chart must be commenced. Residents are regularly weighed and this is recorded. Although residents likes and dislikes with regard to food are recorded, full nutritional screening should be undertaken on admission and on a periodic basis. There is a policy in place for the receipt, recording, storage, handling, administration and disposal of medicines. A monitored dosage system is used. Appropriate records are kept of all medicines received, administered and leaving the home. A sample of the medication cassettes and administration records were seen during the inspection and there were no discrepancies. It was noted during the medication round that staff were not waiting to observe residents take their medicine before signing its administration. The majority of staff who administer medication have successfully completed the accredited medication training. The majority of residents have single rooms and all personal care giving takes place in private. The home has hand-held telephones, so that residents can make and receive calls in private, if they wish. Residents wear their own clothes at all times. Staff are instructed during induction on how to treat residents with respect and this also forms part of their NVQ training. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 11 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): 13, 14 and 15. The home does have links with the local community, although some relatives and residents feel that residents should be given opportunities to go out locally on a regular basis. Residents are able to exercise choice, but choice to go out for a walk when desired is limited by staff ratios. The meals in the home are of excellent quality, although there are concerns about works required in the kitchen (see Standard 26). EVIDENCE: The majority of residents have their own rooms, where they are able to see their visitors if they wish. Otherwise visits can take place in any of the communal rooms. There is no separate visitors room and one resident commented that she would like this, so that she could see her relative in private. A representative of the local Church visits to conduct a service each month. A relative commented that some of the residents would like to go out more, if only to the local shops or garden centres. Residents spoken to felt that they were able to exercise choice over their lives. One said that she could get up when she wished in the mornings and that if she felt like a “lie in” she could have one. Several residents like to sit up late at night, watching T.V. Residents are able to take charge of their finances if Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 12 they wish, but none of the present residents do. The majority of residents request their families to do this. Residents clearly enjoy their food at Castlefort Grange. The lunchtime meal during the inspection was tomato soup, followed by roast chicken with stuffing and vegetables, followed by Manchester tart. The meal was of excellent quality and very much appreciated, with seconds being offered. The cook has been working at the home for some years and knows the residents well. She is aware of their likes and dislikes and often discusses menus with the residents. An alternative is always available for the main meal and special diets are provided where needed. Food supplies were seen to be adequate and of good quality. Only sterilised milk is provided and it is recommended that a choice is offered. It appears that there is no room to store pasteurised milk in the fridge and therefore an additional fridge must be provided. Fridge and freezer temperatures are taken and recorded on a daily basis. The temperature of meats is also recorded. It is recommended that antiseptic wipes are purchased to wipe the probe. Although staff were attentive to residents during the meal, it was noted that one person needed more assistance than she was given and it is recommended that one member of staff remain with the residents during the mealtime, rather than going backwards and forwards to the serving hatch. Whilst this should be possible at lunchtime, when there are 3 care staff “on the floor”, afternoon rotas show that 1 carer serves the tea-time meal (see Standard 27 – staffing). Because of the good quality of the food, this Standard is given a score of 4. There are, however, serious concerns with physical standards in the kitchen, which are addressed in Standard 26 – Hygiene and Control of Infection. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 13 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. Although there is a Complaints Procedure in place, this does not appear to be working, as concerns about the environment expressed by residents have not been acted upon. The home’s Adult Protection Procedure needs to be in line with the Department of Health guidance, “No Secrets” and the local Social Services Adult Protection Procedure. EVIDENCE: Although the home has a complaints procedure in place, in addition to recording “comments” made by visitors, there is evidence that some concerns from residents and relatives are not acted upon. This is primarily true of concerns about the physical environment of the home. From their comments, residents are clearly unhappy about the state of the carpet in the hall and lounge and were at the last inspection. Although the Registered Provider had arranged for the floor covering to be replaced the following week, his response to concerns made had been tardy. This does not give residents and relatives confidence that their concerns will be acted upon in a timely manner. Since the last inspection the home have acquired a number of written procedures including an Adult Protection Procedure. This is not, however, in line with the Department of Health guidance, “No Secrets” or the Walsall Social Services Adult Protection Policy. The home must ensure that their policy is in line with these documents, particularly in regard to procedures following any allegation of abuse. The registered manager is clear of her responsibilities under the Protection of Vulnerable Adults Scheme. Staff are booked to go on Adult Protection Training in November 2005. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 14 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. Progress on improving the environment remains slow and is causing some residents, relatives and staff to be frustrated. Some serious matters remain outstanding, which put residents at risk and do not provide safe and comfortable surroundings in which to live. EVIDENCE: The requirement made at the last inspection that a written programme of routine maintenance and renewal of the fabric of the building be forwarded to the Commission has still not been met. This must give a clear indication of how and when compliance with environmental standards will be achieved. The gardens have been greatly improved since the last inspection and residents were able to sit out during the summer months. At the time of the inspection there were outstanding requirements both from the Fire Officer and the Environmental Health Officer. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 15 A tour was made of the building and the following areas are in need of attention: Carpets in the lounge, hall and corridor areas are dirty. These were due to be replaced with alternative floor covering within the next few days. Some of the armchairs in the lounge are torn and must be replaced. Room 11 – the wardrobe door does not close properly – the wardrobe must be replaced. The easy chair must be replaced as it is broken and dangerous. The room must be provided with a bedside light. Room 12 – exposed pipework must be boxed in. Room 14 – radiator cover must be fitted and painted. Room 15 – the bed must be provided with a comfortable mattress cover. Room 16 – requires a new easy chair. The flooring is uneven and needs attention. The radiator cover is not fitted or painted. The room does not have a suitable lock and key. Room 17 – the window cannot be opened as the key has broken in the lock. The radiator cover is not fitted or painted. Pipework in the en suite toilet must be boxed in. The easy chair needs replacing. Room 18 – radiator cover needs fitting and painting. A new easy chair is required. The door does not close into its rebates. Room 22 – there is no radiator cover, the light cord cannot be reached from the bed. Room 23 – needs decorating, the chest of drawers is broken and needs replacing, the towel rail is broken in the en suite toilet. Room 3 – the automatic closure to the door needs adjusting, as it closes violently. Room 5 – currently has old carpet in here (which must be removed) and needs new furniture throughout. Rubbish outside this bedroom window must be removed. Room 9 – radiator must be covered. It is recommended that divan beds are provided with valances. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 16 Ground floor bathroom – radiator must be covered and pipework boxed in. The fire door in the hall does not close properly into its rebates. The single toilet on the first floor has a broken lock. Bathroom on the first floor needs decorating. The portable hoist must be removed and stored elsewhere. The shower must be repaired or removed. The radiator must be covered. There is no radiator cover in the ground floor shower room. The Burco boiler must not be stored in this room. The temperature of the water at outlets accessible to residents must be checked on a weekly basis and the temperature recorded. Several areas of the kitchen need attention: kick boards must be replaced, currently the floor cannot be properly cleaned. A fly screen must be provided. The laundry has been provided with an air-cooling system, but this appears to be ineffective as staff report that the room continues to be exceptionally hot. The floor covering in this room is not flush with the wall and cannot be adequately cleaned. The lock to the cupboard in which hazardous substances are stored is broken. The Environmental Health Officer is due to re-visit within the next few weeks to ensure that his requirements with regard to the laundry have been met. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 17 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 and 30. Care staff are employed in sufficient numbers, but the lack of sufficient ancillary staff means that there is a risk of residents’ needs not being met. Staff are achieving well with the National Vocation Qualification training. A training plan is not in place and induction training for new staff is falling well short of the required standard. This may have the potential to place residents at risk from inadequately trained new staff. EVIDENCE: Currently the home employs 3 care staff on day time shifts (from 8.00 a.m. to 10.00 p.m.) and 2 waking night staff. A senior member of staff is on call “out of hours” in the event of an emergency. As at the last inspection, the home have not employed a cook to prepare and serve the tea-time meal. This means that a member of care staff prepares tea and is consequently not available during this time for care duties. Two care staff “on the floor” is insufficient to meet the needs of the current residents and this short fall must be remedied. If the home finds it impossible to recruit a cook, an extra member of care staff must be brought in to prepare and serve the tea-time meal. The home have also been unable to recruit a cook to prepare the lunchtime meal at weekends. Currently either the Manager or Deputy Manager come in to carry out this task. They also cook lunch when the cook goes on holiday, thus taking them away from their managerial duties. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 18 Residents seen during the inspection felt that they were well cared for by the staff. Staff are clearly very committed to providing a quality service, but feel frustrated about the amount of unfinished work to the environment. 70 of the care staff have completed their NVQ2 award and several hold the NVQ3 award. The home does not have a training plan in place and this needs to be developed. There are induction packs in place at the home, but these have not been completed by new staff. The home must ensure that all staff receive induction to Skills for Care specifications. The registered manager has held discussions with a local Training Organisation and hopes that these issues will shortly be resolved. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 19 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 Registered Manager is qualified and experienced and committed to providing the residents with a good quality of life. Although residents are clearly consulted, the home does not have a formal system in place to ensure that residents’ views are sought and acted upon. Residents’ monies are kept in good order, but Bank Accounts should be opened to ensure security. The home still needs to develop its risk assessments procedures for ensuring that the health, safety and welfare of residents and staff are protected. EVIDENCE: Both the Registered Manager and Deputy Manager have achieved the Registered Managers’ Award. The manager is experienced and is well respected by residents, their relatives and staff. The manager takes part in periodic training to update her skills and knowledge. Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 20 Residents’ meetings are held and their views are sought on an informal basis. A “comments” book is available for visitors. The home does not, however, have a formal quality monitoring system in place and has not produced an annual development plan. The Registered Person must produce a monthly report on the conduct of the home and send a copy of this report to the Commission. The majority of the residents request that their relatives take charge of their finances. Some, however, request that the home look after monies on their behalf. It is strongly recommended that individual bank accounts be opened for these residents. The monies and accompanying records were checked at the inspection and there were no discrepancies. The majority of care staff have been trained in the mandatory health and safety areas of first aid, fire safety, moving and handling, food hygiene (for those who prepare food) and infection control. The Registered Manager is currently in discussions with a local training organisation to ensure regular updating of this training. Currently hazardous substances are not being stored securely (see Standard 26 above). It was found that the Gas Safety check had not been carried out since July 2004. A check was booked during the inspection for the following week. The water is tested for legionella on a regular basis. The hoists were checked and maintained in June 2005 and the lift engineer visited in August 2005. The Registered Person must ensure that the recommendations of the lift engineer are carried out. It is recommended that the Registered Manager compile a Health and Safety folder, so that all related documentation can be kept together for quick reference. The Registered Manager must develop a written statement of the policy, organisation and arrangements for maintaining safe working practices. Risk assessment must be carried out on safe working practice topics and a separate Fire Risk Assessment must be produced. The home must ensure that all accidents, injuries and incidents of illness or communicable disease are reported to the Commission. 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.V256446.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 1 X X X 2 1 2 STAFFING Standard No Score 27 2 28 3 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 22 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 OP4 Regulation 18(1)(c)(i ) 13(4) 15(2)(b) Requirement Timescale for action 30/11/05 2 3 OP7 OP7 4 OP7 15(1) Care staff must receive regular, ongoing training in the needs of people with dementia. (Previous timescale of 31/07/05 not met). There must be a falls risk 30/11/05 assessment in place for each resident. The home must ensure that 10/10/05 where residents are on respite stays, a formal review is held before any decision is reached to admit the resident to long-term care. Care plans must set out in detail 30/11/05 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 residents are met. They must indicate how issues are to be dealt with and the desired outcome for the resident. (Previous timescale of 31/07/05 not met). Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 23 5 OP8 17(1)(a) Schedule 3 (p) 6 OP8 17(1)(a) Schedule 3 (o) 7 OP9 13(2) 8 9 OP26 OP16 13(4)(c) 17(2) 10 OP16 17(2) 11 OP18 12(1)(a) 12 OP19 23(2)(b) 13 OP19 23(4) All residents must have a pressure sore risk assessment on file. A record must be kept of the incidence of pressure sores and of treatment provided to the service user. Nutritional screening must be undertaken for all residents on admission and on a periodic basis. Where there are concerns about diet and fluid intakes, a diet and fluid intake chart must be commenced. Staff must not sign to verify that a medicine has been taken until they have observed the resident take it. Suitable refrigerated storage must be provided for the milk. Residents and relatives must be assured that their concerns and complaints will be acted upon in a timely manner. Records must be kept of all complaints made and include details of the investigation and any action taken. (Previous timescale of 30/06/05 not met as a Complaints Record Book has still not been provided). 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 timescale of 31/07/05 not met). The home must forward to the Commission a written programme of routine maintenance and renewal of the fabric of the building. (Previous timescale of 30/06/05 not met). The registered person must ensure that all the requirements of the Fire Officer are met. (Previous timescale of 31/07/05 not met). DS0000020808.V256446.R01.S.doc 30/11/05 21/10/05 10/10/05 31/10/05 11/10/05 31/10/05 30/11/05 30/06/05 30/11/05 Castlefort Grange Version 5.0 Page 24 14 OP20 16(2)(c) 15 OP20 16(2)(c) 16. OP21 23(2)(d) 17. 18. 19. OP22 OP24 OP25 23(2)(l) 16(2)(c) 13(4)(a) 20 21 22 23 OP25 OP26 OP38 OP26 13(4) 16(2)(j) 13(3) 16(2)(j) Carpets must be replaced in the lounge, corridors and hall area. (This was due to be done in the week following the inspection). All broken and torn armchairs must be replaced (both in communal areas and individual bedrooms). Those which are dangerous must be replaced immediately. The first floor bathroom must be redecorated and the floor covering replaced. The shower must be replaced with a suitable shower or removed. The radiator must be covered. (Previous timescale of 31/08/05 not met). Suitable storage must be found for the portable hoist. (Previous timescale of 31/08/05 not met). All those areas listed as needing attention in individual rooms must be dealt with. Water temperatures at outlets accessible to residents must be checked on a weekly basis and recorded. All pipework and radiators must be guarded. (Previous timescale of 31/07/05 not met). Kick boards must be repaired in the kitchen. A fly screen must be provided. All hazardous substances must be kept securely. The requirements of the Environmental Health Officer must be met with regard to the laundry. 31/10/05 30/11/05 30/11/05 31/10/05 30/11/05 11/10/05 30/11/05 31/10/05 11/10/05 31/10/05 Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 25 24 OP27 18(1)(a) 25 OP27 18(1)(a) 26 OP30 18(1)(c) 27 OP30 12(1) 28 OP33 24 29 OP33 26 30 OP38 13(4)(a) 31 OP38 23(4) 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 timescale of 31/07/05 not met). A person must be employed to carry out laundry duties. (Previous requirement of 31/07/05 not met). The home must develop a training plan and forward a copy of this document to the Commission. All members of staff must receive induction training to Skills for Care specifications within 6 weeks of appointment to their post. The home must develop a system for effective quality assurance and quality monitoring, based on the views of residents and their representatives. The Registered Person write a monthly report on the conduct of the home and provide the Commission with a copy. The Registered Person must ensure that the recommendations of the lift engineer are carried out. The registered manager must carry out a Fire Risk Assessment (previous timescale of 31/07/05 not met). 31/10/05 31/10/05 30/11/05 30/11/05 31/01/06 11/10/05 18/11/05 31/10/05 Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 26 32 OP38 12(1) 33 OP38 37 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. (previous timescale of 31/07/05 not met). The home must ensure that all accidents, injuries and incidents of illness or communicable disease are reported to the Commission. 31/10/05 11/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that care plans are organised so that each resident has a separate folder, which includes both their assessment information and care planning information. Files should have an index and different areas be separated by dividers. It is recommended that one member of staff remains with the residents during mealtimes, to ensure that those that need assistance receive it in a timely manner. 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 “Dissolvo” bags are used for foul laundry. It is recommended that individual bank accounts be opened for any residents who request that the home take charge of large amounts of money on their behalf. It is recommended that the Registered Manger compile a Health and Safety folder. 2. 3. 4. 5. 6. OP15 OP12 OP26 OP35 OP38 Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Castlefort Grange DS0000020808.V256446.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!