Inspection on 16/05/07 for Castlefort Grange

This inspection was carried out on 16th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Castlefort Grange 30/03/10

Castlefort Grange 07/05/09

Castlefort Grange 09/11/06

Castlefort Grange 10/05/06

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 Keith Salmon Key Unannounced Inspection 16th May 2007 09:30 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.V340441.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 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 (15), Old age, not falling within any registration, with number other category (23) of places Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Maximum number of registered beds 23 (twenty-three) at any time No number division between categories except 15 (fifteen) beds may be used for (DE) Dementia or (OP) Older People 9th November 2006 Date of last inspection Brief Description of the Service: Castlefort Grange is registered to care for 23 older people, 7 of whom may require dementia related care. Situated in the Walsall Wood area of Walsall, there are local amenities and shops reasonably close by, though not within walking distance for the majority of Residents. However, with satisfactory public transport links close at hand access to Brownhills and Walsall is readily achievable. The Home has recently undergone major building work providing additional rooms, and increasing the size of some existing bedrooms to include an en-suite toilet. Accommodation now totals 17 single and 3 double bedrooms. In addition, the lounge has been extended and a conservatory added. There is also a separate dining area and large, accessible garden. The current scale of charges range from £337.29 to £390.00 per week. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection of ‘Key’ Standards commenced at 9.30am, concluded at 5.00pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home was Mrs Jean Riggs (Registered Manager), who was later joined by Mr. Mervyn Ricketts (Proprietor). In addition to inspecting the ‘Key’ Standards, this Inspection also sought to review progress made in meeting ‘Requirements’ arising from Inspections held in November 2006 and March 2007. This Report is based on observations made during a tour of the premises, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the Home. The Inspector also held individual discussions with 10 Residents, 3 Visitors, the Registered Manager, the Proprietor, and several members of Care Staff. What the service does well: What has improved since the last inspection? At the previous Unannounced Key Inspection, held in November 2006, a total of 21 Requirements were issued, or carried forward from previous Inspections. In the intervening months the majority of these, covering a number of areas critical to provision of a safe, good quality service, have been satisfactorily met, e.g. Care Planning Documentation has been further developed and now include details of Resident’s interests and personal preferences. Introduction of a ‘Key Worker’ system. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 6 Details relating to imminent social and leisure activities/events are now readily available and accessible to Residents/Visitors. Adult protection procedures have been updated. Fire safety measures have been updated in line with recommendations by the local ‘Fire Safety Officer’. The remaining Requirements have received positive attention and are now regarded as Recommendations for ‘good practice.’ 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. The summary of this inspection report can be made available in other formats on request. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents (or their Representative) are provided with the information they need to make an informed choice about ‘where best to live’ Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: A Requirement from the previous Inspection was – “Following assessment, the Registered Manager must write to the service user confirming that the home is able to meet their needs.” Systems have now been modified, e.g. Service User Guide and pre-admission visits, to ensure prospective Residents (or their Representatives) are made aware of the ability of the Home to provide them with appropriate care. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 9 Two Service Users, who recently took up residence, confirmed to the Inspector they were happy with the level of information provided, and with the manner in which it was supplied. This information had helped when making their decision. The Inspector considers this Requirement to be met. ‘Case tracking’, which included review of six randomly selected Resident’s Records/Care Plans, demonstrated that prior to any offer of a place in the home, and subsequent acceptance of the offer, all had undergone assessment of their care needs by the Registered Manager. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home sets out Resident’s health, personal and social care needs and enables them to meet assessed care needs. The care provided is delivered considerately and effectively. The storage, reception, disposal, and record keeping, relating to medicines administration are generally in accordance with accepted ‘good practice.’ However, a shortfall in respect of ‘good’ practice remains in the lack of a purpose designed medicines trolley. Residents’ privacy and dignity is respected. EVIDENCE: Four Requirements were made at the previous Key Inspection in relation to the management of Resident’s Care Plans. Specifically: - Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 11 The need for more detailed action to ensure Care Staff are able to fully and effectively meet health, personal, and social care needs of Residents. The need for evidence of regular (at least monthly) review of care plans. The need for evidence of involvement of the Resident (or ‘supporter’) in drawing up the initial care plan documentation and in any subsequent changes. Review of the care planning documents, relating to the six Residents selected at random for ‘case tracking’, demonstrated the Home uses an in-house design of care plan, which is sufficiently comprehensive to meet Residents’ individual care needs, and reliably maintained by Care Staff. Areas of care addressed by the care plan include; full range of risk assessment based on ‘activities of daily living’, pressure sore risk assessment, nutritional state including daily food and fluid intake, regular weighing (frequency determined by assessed need), and records of visits by clinical/social care professionals, e.g. GP, Community Nurse, Social worker, Optometrist. Residents’ interests, hobbies, and preferences are now also recorded. Evidence was also observed of involvement by Residents/’supporters’ in the needs assessment and care planning process, together with regular review (at least monthly, sometimes more frequently), and with change where necessary. A review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures), the maintenance of medicine administration records (MAR Sheets), and the maintenance of the Controlled Drugs Register. The Inspector also reviewed the contents of the medicine cupboard, and systems/records relating to the receipt and disposal of medicines. It is noted the Home does not have a medicine trolley – medicines being administered from monitored dose cassettes, which are pre-loaded on to an open trolley for each ‘medicine round’. Whilst this system is generally safe in terms of individual Residents receiving the correct medication the Inspector does have some concern regarding the security of individual cassettes. The recommendation the home obtains a ‘medicine trolley’ will remain. A further Requirement, in this ‘Outcome Group’, related to the need for more specific detail with regard to particular clinical procedures. The Inspector observed that, where relevant, more detailed information is now being entered in care plans. The Inspector considers all of the above Requirements have been met. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Leisure opportunities provided are generally consistent with Residents’ capabilities. However, activities provided for Residents with dementia related needs should be developed further. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: At the previous Key Inspection two Requirements were issued under this Outcome Area. These related to Residents’ awareness of planned social and leisure activities, and the lack of provision of specialised activities designed for those Residents with dementia related problems. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 13 The Inspector observed information relating to imminent events is now posted on a white board in the reception area. In addition, care plans now record individual Resident’s interests and personal preferences, which is a useful adjunct to the effective deployment of Care Staff in their ‘key worker’ role. As a consequence Staff are able to focus more effectively on enabling Residents to enjoy activities consistent with personal preferences and capabilities. The inclusion of Resident’s expectations and capabilities in care plans, plus the introduction of the ‘key’ worker’ system, has, to some degree, facilitated an improvement in provision of activities of specific value to those Residents with varying degrees of dementia. A clear example of progress is that some Residents now undertake simple ‘domestic’ tasks, such as folding items of clothing following laundering. Evidence was seen of appropriate risk assessment, and, Residents, who were able, informed the Inspector they enjoyed this sort of activity, affording them feelings of “value and self respect”. Therefore, as discussed with the Manager, it will be a recommendation that activities provided for Residents with dementia related needs should be further developed, e.g. activities within arts and crafts, reminiscence sessions, music and movement. The main meal of the day is publicized on a white board in the entrance hall. Residents spoken with considered the food provided was of very good quality, suitable amounts, hot (when appropriate), and nicely presented. As Care Staff know the Residents well they are aware of their personal likes and dislikes. Residents confirmed they have something different to the ‘menu of the day’ if they so wished. Three main meals are provided, including a cooked breakfast when required, with drinks and snacks available between meals, and at suppertime. Menus observed demonstrated a variety of nutritious foods are provided, with puddings and cakes usually being homemade. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse. EVIDENCE: A Requirement carried forward from previous Inspections and relating to this ‘Outcome Area was “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.” As acknowledged in the previous Inspection Report this issue was being addressed. A review of staff records, discussion with the Manager and other Staff provided evidence this process has now been completed. This Requirement is met. At the time of this Inspection the Inspector was aware that an ‘Adult Protection’ Meeting had been convened for two days after the inspection visit. In the interest of not inappropriately influencing the findings, and conclusions, of that Meeting, the Inspector will not comment here, beyond stating the Home appears to have kept records of events as they perceived them – records which are in accordance with related Regulations and Standards. A review of current complaints/incidents systems found them to be satisfactorily maintained with resultant action taken to improve any shortfalls in service provision. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a generally safe, well-maintained environment with communal rooms and bedrooms, which are satisfactorily decorated with furnishings being in good order and presenting a ‘domestic’ ambience. Previously noted improvements aimed at making Castlefort Grange a safer and more comfortable environment have continued. Specialist equipment, consistent with meeting the assessed care needs of service users and the demands of tasks carried out by Care Staff, and is appropriately serviced and maintained. The home is clean and there are satisfactory standards of hygiene. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 16 EVIDENCE: Requirements made at the previous Key Inspection in relation to ‘Environment’ comprised “The registered person must ensure that all the requirements of the Fire Officer are met. All fire doors must close firmly into the rebates.” “The separate toilet on the first floor must be re-decorated.” “ The bath panel to the bathroom on the first floor must be repaired.” “All those areas listed as needing attention in individual rooms must be dealt with.” A tour of the Home provided evidence that fire doors now close in their rebates. This aspect of the Requirement is met. However, with regard to other aspects of these Requirements the Inspector found a mixed response. Some elements referred to as “…areas listed…” have been addressed, whilst others have received no attention. Those addressed and met include: Wheelchairs are no longer stored in the recess area in the lounge Room 18, used as a storeroom, was found to be locked (as required) Bricks and rubbish outside Room 5 has been removed Matters still in need of attention include:The separate toilet on the first floor remains in need of redecoration The bath panel to the bath in the first floor bathroom remains in need of repair The Inspector was informed there are proposals to review the use of these two sanitary facilities and the work will be undertaken when a decision is made with regard to their future use. Whilst it is accepted the outstanding works noted above are part of future plans for improvement it was unclear to the Inspector as to what the time frame for such work might be. It is ‘Recommended’ the home draw up an on-going redecoration/refurbishment plan, with target dates for completion and this plan shared with CSCI. Another area raised in the previous Inspection Report related to some bedrooms being in need of brightening up through the provision of pictures and ornaments. It was previously ‘Recommended’ that Relatives be requested Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 17 to assist Service Users to personalise rooms to their taste and/or for the home to consult with the Service Users as to what they would like in their Rooms. The Inspector was informed the process of involving Relatives has commenced. Further to this, the Manager accepted there would be distinct advantage in incorporating this activity, within the remit of Care Staff, when undertaking their ‘Key Worker’ role. In addition, a number of Recommendations were made with regard to improving comfort/convenience for Residents in the communal living areas i.e. That dining room chairs be replaced with ones which have arms thus making them easier to manoeuvre That additional small tables be provided for Service Users on which to rest their drinks and snacks It is accepted that all Residents may not need such furniture, or, indeed, that constraints of available space might prevent the wholesale introduction of more or larger items of furniture. However, it is ‘Recommended’ the Manager undertake a review/’risk assessment’ of all Residents to determine specific need with a view to provision where appropriate, and that consideration be given to provision of dining chairs with arms, which may offer a safer/more convenient option for Residents/Staff. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers and skill-mix listed on the staff rota are sufficient to meet the assessed care needs of current Residents. Application forms submitted by some employees lack sufficient detail to ensure the safeguarding of Residents. The commitment of the Home to providing training for Care Staff is good. EVIDENCE: A number of Requirements were made at the previous Key Inspection in relation to ‘Staffing’. These were in respect of employment practices and records/documentation, i.e. Two written references to be obtained before appointment of new staff Staff employed on the basis of a ‘POVA First’ check, must be ‘risk assessed’ and supervised at all times Application forms for new employees to contain a full employment history and any gaps explained Staff training and related record keeping Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 19 Review of a random selection of staff employment files and supervision files provided evidence that, whilst elements relating to ‘POVA’ and CRB checks are now adhered to, in some instances the level of information captured by the application form is sparse and inconsistent. For example, it was not possible to build a picture of previous employment history of several applicants, whilst at the same time others were satisfactory. Therefore, to reflect the importance of gathering as much information as possible relating to prospective employees, prior to appointment, it will be a ‘Requirement’ of this Inspection that the Manager undertakes a review of all practices, documentation, and recordkeeping, in respect of recruitment, with a view to establishing a more thorough and consistent system, which is fully in accordance with this Standard. With regard to formal ‘supervision’, evidence of an annual appraisal for all staff was observed. However, records relating to on-going formal ‘supervision’, whilst in existence, were rather patchy. The Manager explained this was an area she had not been able to address since taking up post, but it was on the agenda to receive attention in the near future, with plans which should make the process more ‘user friendly’, for both the staff member and ‘supervisor’. These plans were discussed with the Inspector, who is satisfied there should be improvement in this area by the next Inspection. Two further Requirements related to arrangements for staff training, i.e. Staff must have individual training and a development assessment profile All new members of Staff must receive induction training, under the ‘Skills for Care Specifications’, within 6 weeks of commencing employment A review of staff training files, and the staff training programmes, demonstrated Staff are subject to a thorough, and relevant, orientation/ induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘fire safety’, ‘manual handling and lifting’, ‘first aid’, ‘simple infection control’. As such these Requirements are met. As with records related to employment practices previous poor performance in the keeping of ‘supervision’ records, seems to have been due, in part, to inadequate record keeping both in systems design and in the maintenance of current entries by the previous management regime. Evidence was seen confirming the (relatively) new Manager is in the process of remedying these shortfalls. Currently 50 of care staff have attained NVQ Level 2 or better. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 20 A Requirement relating specifically to the provision of domestic staff suggested the numbers employed might not be sufficient to maintain the Home in a clean and hygienic state. With this in mind the Inspector looked particularly at general ‘cleanliness’ and hygiene during the tour of the Home, held a discussion with the domestic staff member on duty (the other member of the domestic staff team was taking annual leave), discussion with the Manager, and with Residents and visitors. The total provision of domestic staff ‘hours’ equals 50.5 hours per week, with one staff member providing shifts 5 days per week, the other 6 days per week. Although the cover is occasionally reduced to one staff member the ‘shortfall’ is managed through deployment of the remaining staff member to areas of work adjudged by the Manager as essential, e.g. toilets and bathrooms. Given the Home was operating in this mode at the time of the Inspection, the Inspector was able to determine whether this reduced the effectiveness of cleaning and maintenance of safe hygiene levels. The judgement of the Inspector is the home presented as a clean, pleasant and odour free environment, and the number of staff comprising the domestic team, and their deployment, is adequate. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is provides an ambience, which is warm, friendly, and inclusive with the central purpose being ‘the best interests of residents’. Operationally, the Home is now better organised with lines of accountability being clearly defined and observed. Service Users are safeguarded by the financial procedures operated in the home. Staff, who appeared involved, and happy, in their work. However, the process of formal supervision could be improved. Health and Safety Policies/Procedures/Practices were satisfactory. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 22 EVIDENCE: Observation by the Inspector, comments from Residents, Staff, and Visitors, evidenced the Home is now being better managed. Virtually all of the Requirements arising from previous Inspections pre-date the current Manager’s tenure in the post, and it was clear to the Inspector that many have been effectively addressed. For those not yet met, there is sufficient evidence to indicate these will be confronted and met within a reasonable timescale. The financial management of small amounts of cash, to cover incidental items, for a few Residents, is conducted by the home, with records audited on a regular basis. The Inspector reviewed transaction records, and found them to be managed in accordance with the Standard. All other records were seen to be secure and well maintained. Practices in the context of health, safety and welfare of Residents, Visitors, and Staff were seen to be in accordance with the Regulations, i.e. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Records of regular checks on hot water temperatures at outlets accessible to Residents showed temperatures to be in accordance with the relevant Standard. A review of staff records revealed one specific area in which improvement is both desirable and necessary, i.e. record keeping relating to formal supervision of staff. Once again this is an area the Manager has begun to address. It was noted in the previous Inspection Report that “In some of the en suite bathrooms unsightly pipe-work needs to be boxed in.” Apart from a visual untidiness, there may be the possibility of Residents sustaining burns from pipes delivering hot water. Checks by the Inspector, at the time of the Inspection, of a sample of exposed pipes, revealed none to be of obvious danger to Residents. However, to fully safeguard this possibility it is ‘Recommended’ that:All exposed hot water pipes in areas accessible to Residents are ‘risk assessed with regard to the possibility of causing burns to Residents Initially any hot water pipes identified as a possible risk to Residents safety are boxed in as soon as possible Other ‘health and safety’ records examined related to fire risk management, nurse call bells, lighting, Legionella, portable electric equipment, hoists. All were found to be satisfactory. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19. – (1) Timescale for action All practices, documentation, and 30/06/07 record keeping in respect of employment, should be reviewed and a more thorough and consistent system established. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP9 OP12 OP19 OP20 Good Practice Recommendations It is recommended the home obtain a dedicated medicine trolley to ensure ‘best’ practice in this important area of care. Activities provided for Residents with dementia related needs should be developed further. An on-going redecoration/refurbishment plan, with target dates for completion, should be drawn up and a copy provided to the CSCI for their information. It is recommended the home undertake a review/’risk assessment’ of all Residents to determine specific need in relation to particular items of furniture in the communal rooms. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 25 5. OP38 It is recommended that a ‘risk assessment’ be carried out on all hot water pipes and any found to present a risk to Residents should be boxed in. Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Castlefort Grange DS0000020808.V340441.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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