Inspection on 30/03/10 for Castlefort Grange

This inspection was carried out on 30th March 2010.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Castlefort Grange 07/05/09

Castlefort Grange 16/05/07

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 03/09/2010.

Key inspection report Care homes for older people Name: Address: Castlefort Grange 39 Castlefort Road Walsall Wood Walsall West Midlands WS9 9JL     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Monica Heaselgrave     Date: 3 0 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 41 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 41 Information about the care home Name of care home: Address: Castlefort Grange 39 Castlefort Road Walsall Wood Walsall West Midlands WS9 9JL 01543371754 01543454353 castlefort.grange.care@unicom.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Castlefort Grange Care Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 23 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 23 Dementia (DE) 23 Date of last inspection Brief description of the care home 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 people using the service. However, with satisfactory public transport links Care Homes for Older People Page 4 of 41 Over 65 0 23 23 0 0 7 0 5 2 0 0 9 Brief description of the care home close at hand access to Brownhills and Walsall is readily achievable. The home has 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. Care Homes for Older People Page 5 of 41 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We carried out an unannounced visit to the home which means that the provider did not know that we were coming. The visit was undertaken to establish if the service is run to the best interest of those who live there and offers a good quality and safe service. Prior to the visit we looked at a variety of information. This included things the Service must tell us about such as any accidents or concerns that have taken place. We looked at information provided from complaints or concerns expressed about the service from external agencies. We were unable to look at the Annual Quality Assurance Assessment that the service is required to complete. The provider did not send us this prior to our visit. The provider received a warning letter to this effect. The Annual Assurance Assessment was presented to us on the day of our visit. This was poorly completed and did not provide up to date information as to how the Service is run. During our visit we tracked the care for three individuals looking at all the documentation in respect of their care. We observed practice and talked to the people Care Homes for Older People Page 6 of 41 who live there as well as the staff and acting manager. We reviewed a range of other documentation as well as looking around the building. The provider was present for part of the visit and our feedback Care Homes for Older People Page 7 of 41 What the care home does well: What has improved since the last inspection? What they could do better: The process of pre assessment must be robust and provide a clear framework for the assessment of needs. This is to ensure the needs of the individual are identified prior to being admitted and a placement will be offered to people only where the home is able to meet these needs. Each person must have a care plan that provides clear guidance about how to meet their care and healthcare needs. Care plans should be person centred and show the support for each person in the home including those with dementia and other specialist needs such as behaviour that challenges. Appropriate measures must be put in place to minimise the risk of pressure ulcers. This must include the use of pressure relieving equipment. Records must be maintained that show pressure relief is consistently carried out as per clinical advice. People at risk of weight loss must have appropriate nutritional screening to identify their risk. Monitoring records such as food and fluid balance charts must be consistently maintained to demonstrate the steps taken to avoid poor nutrition and the risk of dehydration. Ensure that all staff who administers medication are trained and assessed as competent to administer medication. Ensure that the number of staff on duty are skilled and trained and in sufficient numbers to meet all of the needs of each person using the service. The must be a training programme that demonstrates that all staff is equipped with the knowledge and skills to meet the specialist needs of the people being cared for. Staff Care Homes for Older People Page 8 of 41 should have appropriate mandatory updates and other specialist topic training according to their role and responsibilities. A structured staff supervision system should be resumed to ensure all staff receive formal supervision at least six times each year to provide them with support and development to meet the needs of people using the service. The proprietor must ensure a manager is registered with CQC to ensure the effective management of the service. There is a serious lack of managerial and supervisory support to this home. We cannot be sure that people are safe or get the right care. A lack of training a number of incidents and a serious lack of monitoring indicates poor outcomes for people. To implement an effective quality monitoring system which demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. To ensure notifications are submitted to the Care Quality Commission of any incident that has affected the health, safety or wellbeing of the people at the care home without delay. Management systems must be implemented to ensure safe working practices. This includes the provision of a first aider. The testing and recording of safe water temperatures to avoid the risk of scolding must recommence. Food safety records and checks must be carried out. Safe working practices must be consistently followed and documented. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 41 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 41 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been little progress on providing people with current information about the home in order for them to make an informed choice about moving in. The needs of people are not thoroughly assessed prior to them moving in. This means there is little consideration of the care the individual requires and may result in poor quality of care. Evidence: The previous report recommends that people have up to date information about the services the home provides. The AQAA which was completed prior to this visit tells us that the Statement of Purpose and Service User Guide will be updated but we saw that there has been no progress on these documents being made available. The acting manager told us that in the interim they have produced a leaflet about the home to tell people what is available. The AQAA tells us the complaints procedure will be displayed and we saw this was in the foyer to guide people. It has been twelve months since the home was advised to provide people with updated information about the home in order to make an informed choice about moving in. The home appears to be Care Homes for Older People Page 11 of 41 Evidence: struggling in making progress. When people are considering moving into a home there should be a full assessment of their needs so that the home can determine if they can meet their needs and confirm to them that their needs will be met. We found the quality of the pre admission assessment ito be poor. It does not ensure that any person wishing to use this service has a full assessment of their needs prior to moving in. The previous report recommended that people have a full pre assessment especially if they are returning from hospital as their needs may have changed and the service must ensure they can meet them. We saw three pre assessments and found these are not comprehensive and lack significant detail. The pre assessments we saw did not provide comprehensive or personal detail about the needs of the person. For example one stated the individual has dementia. It did not provide information as to how this affects the person or his behaviour or any risks or specific support he may require. We asked to see the care plan. We were told by the acting manager that there was no care plan that staff used the pre assessment as a care plan because there had been no time to write a plan. Another pre assessment stated that the person requires supervision due to cognitive impairment and poor safety awareness. It did not state what assistance or aids may be required or whether risk assessments were in place to guide staff in the support they needed to provide. We saw on one pre assessment that the person can become aggressive but there were no details as to how the aggression manifests who is at risk or what strategies to use to support the person. This means that care staff has no guidance in providing care or meeting the specific needs of a person who has dementia. We saw that one individual had a number of serious health care needs and would expect to see a comprehensive detail and history taken and a care plan in place. No care plan was available. We spoke to the acting manger who said monthly reviews take place although when we checked the file the review had not been completed. This means the assessment is not thorough and does not provide sufficient information or details as to the needs of the individual to enable staff to determine if they can meet those needs. We found that in all cases there were several blank areas on the pre assessment where the assessor had not explored the needs of the individual. For instance under the Likes and Dislikes section this was blank. Under the Special Needs section this was blank. The Social worker section was blank. On another pre assessment it is recorded that the wife of the person undertakes these tasks but provides no details as to how. This Care Homes for Older People Page 12 of 41 Evidence: means that the personal care routines and preferences are not known this is concerning especially where the individual is unable to voice these. We were notified that the outcome of a recent review identified poor management of one individual. We saw that his pre assessment was not comprehensive. We were told that the person refuses care but records in the home did not provide any information about his behaviour and there were no strategies devised to manage behaviour. This means people cannot be sure that Castlefort Grange will carry out a comprehensive assessment of their needs or meet their needs. The lack of a thorough assessment means the care needs of individuals is compromised and they could potentially be at risk of harm. Care Homes for Older People Page 13 of 41 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of care plans and poor risk management means staff cannot ensure the needs of each person are fully understood and met. Arrangements for the administration of medication ensure that people receive their medicines as prescribed by their doctor. Staff need support and training to meet the health care needs of the people who use the service. Evidence: We were told that usually people who live at the home have a care plan which identifies their support needs and provides staff with information on how their needs should be met. The care plans are designed around key areas of need such as personal and healthcare. The care plan follows on from the pre assessment of needs carried out prior to the person being admitted to the home. The AQAA told us that the needs of people are reflected in their care plans. We asked for care plans for three of the people we had identified as having specialist needs. We found that none of these people had a care plan. The acting manager told us that staff was working from the pre assessment information carried out prior to the people being Care Homes for Older People Page 14 of 41 Evidence: admitted to the home. We were told that the care plans had not been developed because of staff shortages and the fact that the manager had been off sick since September 2009. The deputy had been made up to acting manager in February 2010 but due to staff shortages had little management time to oversee the administrative tasks. The pre assessment information we saw for the three people was inadequate in seeking this information. Staff had little to guide them in providing care and lifestyles in the way people prefer. There was no information to provide a profile of the individual preferences or routines for personal care. Sometimes crucial information was not available. In personal care plans the way individuals needed to be helped should be recorded. We saw that one person was identified as having dementia but there was no detail as to how this affected them or what support they needed or the personal routines they were used to. We saw another assessment that identified the person as potentially aggressive. There was no detail as to how this affects them or how best to support the person. None of the information we saw stated whether the individual liked to have a bath or shower or how their hair should be washed. The pre assessment plan identified that the wife of the individual provided this care. It did not elaborate on the routine or preferences so staff had no guidance on how to carry out this task. We looked at records of one of the people who had some damage to their skin due to pressure. We found the care provided to minimise the risk of pressure sores developing was poor and inconsistent. We found that the records from the District Nurse advised a pressure relieving mattress was needed and a pressure cushion. We tracked the notes and saw that seven days later the mattress and cushion were not available. The records advised standing hourly to help blood flow. We looked in the daily records and found no record of hourly stands. We asked the staff and were told the person was stood when taken to the toilet. We observed on the day of our visit that this person was seated for a minimum of two and a half hours without a pressure cushion or being stood to increase blood flow. We spoke to the staff who told us the District Nurse had visited that day and the person had a pressure sore on their bottom. The records show that between 19th February and the 4th March this person had no pressure relieving mattress. Over the previous six weeks the records we looked at did not evidence a pressure cushion was used or that hourly stands were implemented to improve blood flow. Poor practice could potentially be viewed as neglectful or abusive. We noted that this person also developed some swelling in their hand and arm. This Care Homes for Older People Page 15 of 41 Evidence: was recorded in the District Nurse notes and staff was advised to elevate the arm to improve blood flow. We examined the daily records and saw no entries in these relating to the need to elevate the arm. We observed on the day of our visit the arm was still swollen and not elevated. Further entries in the District Nurse notes refer to the need to elevate the arm. We spoke to the acting deputy about the delay in providing the pressure mattress. She told us that if they had chased it up it would be recorded in the daily records. We looked at these and found no entry. The acting manager could give no explanation as to why this was not done. We found no updated review or care plan to show that this person required hourly stands or elevated arm. There was no information available as to whether this individual required turning during the night to alleviate pressure. This means the recovery of the person is compromised and they are at risk of further health complications. Additionally food and fluids records to show that people were receiving adequate nutrition and fluids were not completed. The home records the food intake for everyone but there was no specific record for individuals at risk of weight loss that would show nutrition is promoted. There was no individual fluid record to show fluids are promoted to prevent dehydration. We noted that this individual had regular weight loss as recorded in his records by the District Matron. There was no plan in place to show how the home intended to promote nutrition. We asked staff who said he would eat small amounts of some foods. We looked at the pre assessment information under the section for dietary needs. This was blank. This meant there was no assessment and management of the degree of risk to individuals at risk of poor nutrition or dehydration. We looked at the information provided in the AQAA. This told us that the home considers a nutritional assessment on people admitted to the home is not applicable. The AQAA asks if the service repeats the screening for people at risk of malnutrition. The home had entered as not applicable. The AQAA asks if the home takes actions to meet the needs of people at risk of malnutrition. The home had entered a yes. There is little or no evidence that regular health monitoring takes place. The indications are that staff do not have the skills, experience or training to meet the health care needs of the people who use the service. Risk assessments were in place for the use of bedrails. Only one person currently requires this and the reason for use was recorded. In view of the lack of documentation regarding nutrition and tissue viability all risk assessments need to be updated. All risk assessments must be fully and accurately Care Homes for Older People Page 16 of 41 Evidence: reviewed when each persons needs change to ensure that peoples health and wellbeing is safeguarded. There should be accurate and consistent records relating to the care being provided to each person. At this inspection we found that daily records did not always include all changes or updates so care staff was not aware of the detail. For example records failed to record whether pressure relief was carried out. Several incidents of aggression had occurred but there was no plan in place to show how personal care was to be offered. The outcome was that one person refused care and his personal care needs had been neglected in part. We did see that medical personnel visited people to ensure that people received adequate health care. Unfortunately care staff failed to follow clinical advice given to them to promote the well being of some individuals. We looked at the homes systems to manage the medication for people accommodated. Staff had not received medication training for some time. They were generally knowledgeable about medication people were receiving. There was no evidence that competency assessments had been carried out to make sure staff were administering medication safely. We also found that there was not always a senior staff member on shift to ensure good practice in this area. We undertook some random audits of MAR charts and medication stocks and found these were accurate. This meant that people were consistently receiving their medicines as prescribed by their doctor. We saw that staff on duty was aware of how to treat each person with respect and to consider their dignity. They interacted in a kindly manner and were tactile and reassuring. However following lunch some people required support to change clothing which had spillages on. The staff did attend to this but several people needed support this could indicate that dependency needs are higher. Some people required attention to their mouth and nose but we did not observe staff offering a tissue. From our observations of people in the home some looked generally well presented whilst others had clothing that appeared either not ironed or over laundered. We noted that in one bedroom a staff notice was evident requesting staff to ensure the person wore socks underclothes and slippers. This information should be detailed in the individuals care plan. Where refusal of care is a concern there must be evidence that this has been explored or investigated with clear alternatives described so that staff knows how to manage the behaviour and the dignity of the person is not neglected. There were a number of concerns highlighted during this visit. We told the acting manager and the owner that there had been a failure to respond to the specific needs of two of the people living at the home. We found unsafe practices that potentially put Care Homes for Older People Page 17 of 41 Evidence: people at risk. We advised that alternative placements needed to be sought. The owner advised that meetings were due to take place the next day regarding one of the individuals who we felt needed nursing care. He agreed to inform the social worker of recent events that indicated the other person needed an alternative placement where their needs could be met. At the time of writing this report both individuals have left the home. There needs now to be a more robust system in place to identify risks and detail these in the care plan. There needs to be a robust system for the monitoring of risks and health care changes to ensure all people living at the home receive effective personal and healthcare support using a person centred approach. Care Homes for Older People Page 18 of 41 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some social opportunities but each person cannot always be assured that there will be appropriate activities for them. There is little consideration of the needs of people with dementia when planning the routines of daily living and arranging activities. Not everyone consistently receives support to maintain an appropriate nutritious diet. Evidence: There was insufficient evidence to show whether the daily routines at the home were flexible to meet individual preferences. The assessment process did not identify preferred daily routines such as rising or retiring. Personal care preferences such as bathing and showering were not identified in the sampled records we looked at. There was no information about previous lifestyle or interests. No hobbies or pastimes had been recorded. The lack of this information severely restricts staff from understanding individual routines or building a good understanding of how to engage individuals in any activities. All three files failed to capture previous history. We raised this with the acting manager and deputy both recognised that there is insufficient information to develop a personal plan of care and activities if information is not captured. Some staff were knowledgeable about individual preferences but this Care Homes for Older People Page 19 of 41 Evidence: was based on verbal communication which could be unreliable. Some people have dementia which restricts their ability to voice their care or social needs. It is very worrying that no attempt has been made to explore their history and develop a care plan with particular consideration for people with dementia to ensure they have opportunities for stimulation through leisure and recreational activities. The acting manager told us that some entertainment comes into the home on a regular basis. The Annual Quality Assurance Assessment completed by the home told us that entertainment is arranged for people such as progressive mobility and visiting entertainers. It did not tell us the frequency of these and there were no other examples of the type of activities that take place. The AQAA tells us that they always make sure that people have choices about their lifestyle and that these are documented in their care plans. The care plans we sampled did not reflect that stated in the AQAA. During the course of the day no activities were evident. The T.V was on in the lounge and music in the dining area. We asked some people how they spend their time one man said he sometimes walks in the garden but mainly occupies himself. We noted that the environment provided conflicting cues for people such as clocks set at wrong times and menu boards displaying the wrong day of the week and the previous menu options. One person asked us what day it was because he was confused with the menu board. We asked the staff if there were some records of activities. They told us this was recorded in daily records. The sampled daily records did not state what people were doing. Staff said they have encouraged people to join in with activities and to use the sensory room. The AQAA says they need to ensure there is sufficient staff to offer activities. The owner said they have had unprecedented sick leave and that the home has struggled. The indications are that there is little evidence of ongoing planning or improvements even though they recognise the weaknesses. There is no evidence that this area is kept under review and no evidence of who is monitoring this. We looked at the staff meeting minutes which showed that staff had discussed the need to develop more activities. This showed us that they recognise this need. However staff said that staffing levels has prevented this occurring. The acting manager agreed that the daily records do not reflect any activities people may be doing and that this needed to improve. The home had an open visiting policy which meant that people were able to maintain important relationships. People we spoke to told us their relatives could visit at anytime. We saw that during the day people either sat in their chair or wondered Care Homes for Older People Page 20 of 41 Evidence: around from lounge to lounge. Staff interacted with them verbally and checked they were ok but there was no observation of staff initiating an activity. Mealtimes are considered to be an enjoyable event. People we spoke to said they enjoyed the meals which they felt were good quality and plentiful. On the day of our visit the acting manager was cooking the main meal she told us she sometimes covers for staff shortages. We noted that at our last visit the meal was also being cooked by the acting manager. Staff and people we spoke with confirmed they are given a choice. We were unable to judge the meal as the owner purchased food from the local chip shop so that the acting manager could support our visit. We did ask what options were provided for those people with nutritional needs. We were told one gentleman had porridge as he liked this. We asked how they support people who have specific dietary needs. Staff told us they monitor nutritional intake. We looked at the care plan this did not identify how nutritional needs are met. We asked to see the monitoring tool and we were told staff record what was actually consumed for all the people in the home. This did not reflect that the nutritional needs of individuals who are at risk of poor nutrition are considered with regular food encouraged and promoted. There were no food and fluid records that would indicate staff are taking appropriate action to ensure people are not at risk of poor nutrition or dehydration. This is very worrying as records show that at least one person has continued to lose weight and we saw no strategy to support these needs. We received a copy of the recent Food Safety Report after the home was inspected in April 2010. This told us that the cooks in the home need to ensure they have time to examine the Safer Foods better Business procedures so that they carry out the necessary food safety checks and complete records to demonstrate this. This indicates that there are concerns about the homes ability to maintain good practice and food safety monitoring. The AQAA tells us that both the cooks and ten of the care staff has had training in safe food handling. We looked at the training matrix this showed that the most recent training was in 2007. The acting manager told us that mandatory training is out of date and that the owner is trying to purchase training however there is no evidence that any training or refreshers have taken place in the last twelve months. Care Homes for Older People Page 21 of 41 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements to safeguard people living at the home do not always protect them from risks of harm. Evidence: The home had an up to date complaints procedure which was displayed in the reception area and we were told this will be contained in the service user guide when this is updated. Information supplied as part of the Homes AQAA indicated that the home had received one complaint in the last 12 months which had been investigated by the provider within 28 days. It stated this complaint was not upheld. The AQAA told us that there were no incidents reported by the home under the safeguarding procedures during the past 12 months. Prior to our visit we received notification of a recent concern regarding physical neglect of one of the people living at the home. We also found from the records of incidents and accidents that a significant number of people had sustained injuries over several months which had not been referred to the Local Authority or to the Commission as a Regulation 37 notification. We spoke to care staff about one individual who was described as presenting specific difficulties with regard to refusing care. We asked them if there was a strategy in place to guide them as to how to manage this behaviour. They were unable to provide this. Staff told us that whilst they would try to encourage the individual this had at times resulted in him being left either partly dressed or lacking personal care interventions. We looked at his pre assessment information and found no information Care Homes for Older People Page 22 of 41 Evidence: relating to his needs in this area. We asked staff if they had training in managing dementia and or challenging behaviour. They were unable to recall any training in these areas. We looked at the training matrix and saw that staff last had training in dementia in 2007 and that no further training or refreshers had taken place and that there had been no training in challenging behaviour. The owner told us that there had been at least three incidents involving assaults on staff. We had not been notified about these. The AQAA tells us what improvements they have made over the last twelve months. The home states that it has displayed the complaints procedure. They tell us that what they could do better is to ensure all staff has appropriate training in all areas. The owner told us he has not secured training for staff in relation to protection. We noted from the AQAA that there had been fifteen admissions to accident and emergency during the last twelve months. The acting manager told us about some of these and acknowledged that these should have been reported to us. She said she had only recently had time in the office to undertake administrative tasks as she had been covering care and cooking shifts. This meant that actions were not appropriately taken to safeguard people from risks of harm. We found there is a lack of recognising potential abuse and reporting it. We found staff had not identified risks and put in place strategies to minimise these. The necessary supervisory and managerial support is not in place to ensure people are safeguarded from risks or harm. The home lacks robust procedures for responding to suspicion or evidence of abuse or neglect including whistle blowing to ensure the safety and protection of people. This includes passing on concerns to the CQC. Care Homes for Older People Page 23 of 41 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the equipment they need to support their assessed needs. However the necessary auditing systems are not in place to ensure people live in a safe environment. Evidence: The Annual Quality Assurance Assessment completed by the care manager told us that the home is clean and tidy and free from unwanted odours. We observed that some improvements had been made such as appropriate storage of items. For example the dining room was no longer used for storing personal possessions and boxes. The main entrance hall had been cleared of boxes containing continence aids and zimmer frames. This means people could negotiate these areas safely without encountering hazards. The lift was in full working order with a certificate of maintenance demonstrating that it has been regularly serviced. We observed that some people require the use of aids such as hoists. We found that hoists had been serviced showing they were safe for use. Wheelchairs and other aids and adaptations were well maintained. People spoken with confirmed their satisfaction with their bedrooms. We viewed some of these and found these to be personalised and comfortable. Furniture flooring and bedding were clean and in good condition. We were told some flooring had been replaced since our last visit to provide more hygienic flooring. Care Homes for Older People Page 24 of 41 Evidence: Where people required the use of bedrails to prevent the risk of falling we saw that these were well maintained with a risk assessment in place showing the reason for use. This means the use of such equipment is used in the best interests and safety of the individual. We were told people have keys to their bedrooms although no one currently utilizes these. We did not see any documentation to reflect if people had been given this option. Each of the bedrooms viewed had a photograph of the occupant to aid orientation. However we observed that in the lounge and dining room both of the clocks were set at the wrong time and the menu board displayed the wrong day and menu. When we asked the acting manager about the confusion this causes she said staff must have forgotten. Bathrooms were well equipped with level flooring hand grab rails and mechanical baths and hoists. This ensures staff has the equipment necessary to support people. We were unable to establish appropriate food hygiene and safety measures were in place. This was because the cooks were not on duty and the main meal of the day was not cooked but purchased. We asked if all staff who handles food had received appropriate food safety training. The training matrix showed that this training was out of date. We received a recent Environmental Services Food Safety Report which identified a number of areas that require improvement. The cooks need to examine and implement the Safer Foods Better Business and carry out the checks and ensure records are consistently completed. We observed that hazardous substances had been secured to minimise the risk to vulnerable people. The garden has level access and included a patio area which is well kept. The AQAA tells us that external walkways have been improved and the patio has been extended. We viewed the rear garden which looked well maintained. The maintenance log showed that repairs are carried out although the system in place for auditing the environment has slipped. The home must ensure that the necessary managerial and auditing takes place to ensure a safe environment. Care Homes for Older People Page 25 of 41 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The number and skill mix of staff do not always ensure that people receive consistently good standards of care. The recruitment processes provide sufficient safeguards for people living at the home. The training programme does not demonstrate that all staff is equipped with the knowledge and skills to meet the specialist needs of the people being cared for. Evidence: There were 20 people living at Castlefort Grange on the day we visited. We were told one of these people was in hospital. From discussion with staff and reading care files we found some people had high dependency levels and complex health care needs. The staff on duty consisted of the acting manager who was undertaking the cooking of meals. A senior staff member was on duty with two care assistants and two domestics. We were told that not all shifts are covered by a senior staff member. We were told five care staff had recently been recruited. There have been occasions when the staffing levels have been below minimum standard. The care manager left the homes employ and the deputy has been acting up in this capacity since February. We looked at a sample of rotas which confirmed that the home has struggled to provide appropriate staffing levels and senior cover on all shifts. There has not been sufficiently allocated care or management hours. This has been compromised by the acting manager covering care and cooking duties and care staff covering senior duties Care Homes for Older People Page 26 of 41 Evidence: such as administration of medicines. The AQAA tells us that 10 staff has NVQ level 2 and we were told that the five new staff has been enrolled on NVQ 2. This means people are cared for by staff who understands the principles of delivering care. We looked at a sample of staff personnel files. The recruitment processes provided sufficient safeguards for people living at the home. There was evidence that all the necessary checks had been carried out prior to staff working in the home. This ensures that the recruitment of staff is robust and ensures that the people were suitable and capable of working with vulnerable people. We cannot be sure that staff is appropriately skilled or trained to meet the assessed needs of the people living at Castlefort Grange. The training matrix showed that there had been no training opportunities since our last visit last year. Care staff had not received all essential training and most mandatory training was out of date. The AQAA states that the service intends to ensure staff are fully trained. The training matrix was analysed and showed that manual handling was last done in 2004 by 6 staff. 1 staff had completed this in 2005 and the most recent training in this area was one staff in 2007. From this record the majority of staff including the acting manager has not done refresher or updated training for six years. This means that staff is not trained to use equipment safely and people could be at risk of poor handling techniques. Two staff did Food hygiene training in 1999. One staff completed this in 2000 and five staff in 2007. We know that when the cooks are not available staff covers this task. This means the majority of staff will need to refresh and update this training prior to handling food. First aid training was last updated in 2005 which means the majority of staff is now out of date. Infection control training was last completed by 10 staff in 2008. Thirteen staff had fire training in 2006. We saw that four staff had a fire drill in October 2009. This means not all staff has had a drill and this which could mean staff do not know the procedures to ensure the safety of the people they care for in the event of a fire. Regular fire drills must be carried out in line with fire safety procedures. Staff last completed safe handling of medication in 2004 and 2006 which means their competencies in this area have not been reviewed. There were no audits to show this area of practice is audited on a regular basis to ensure safe practice. We spoke to the staff that administered the medication. They told us that sometimes there is not a Care Homes for Older People Page 27 of 41 Evidence: senior on duty but that two staff undertakes the medication round. We observed one staff handling the medication. Practices in this area could be unsafe as training is out of date and there is not always a senior staff member to oversee the procedure. There is no delegated person to oversee that safe working practices in all areas are carried out. There was no evidence that audits are undertaken to ensure these aspects are monitored or identify the training needs of staff. It has been difficult for the acting manager to ensure such management tasks are completed and this means we cannot be sure staff is trained and competent to do their jobs. Castlefort Grange provides care for people who have Dementia. We saw from training records that the last training in this area was in 2007. We saw that staff had struggled to meet the specific needs of one person who refused care. This led to neglect of personal care needs. We saw that people had needs in relation to pressure care relief which staff had not consistently followed. We saw that staff had not consistently promoted and monitored nutritional and fluid intake which means people could be at risk from poor nutrition and dehydration. The training record did not show that staff had any training in these specialist areas. This means that there is no evidence that the home is geared towards meeting these needs and that staff lack specific skills in these areas. The service provides a dementia care facility. The owner informed us he is currently undertaking a university course on dementia care. However there is no evidence that the home has addressed this training for the care staff. There has been no training identified for staff in relation to Deprivation of Liberty or the Mental Capacity Act and staff are not aware of how this affects their care practice or the steps they should take to protect people or safeguard their best interests. It was not possible to establish the full teams training needs. There had been a turnover of staff and training records showed no additions in the last year. We found from looking at training records and talking to staff that training opportunities have not been evident. We found no evidence that there are systems in place to identify training needs or target relevant specialist areas or particular staff or their roles. This means the service does not support or encourage the development of a competent staff team. The service must review the team needs with urgency and address training as a priority so that staff has the necessary skills to meet the assessed needs of the people Care Homes for Older People Page 28 of 41 Evidence: they care for. Care Homes for Older People Page 29 of 41 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a serious lack of managerial and supervisory support to this home. We cannot be sure that people are safe or get the right care. A lack of training a number of incidents and a serious lack of monitoring indicates poor outcomes for people. Evidence: On arrival the deputy was covering for the cook. A visitor had also arrived. The deputy explained that the manager had left and she was acting up. A senior member of staff was available. The acting manager contacted the owner to request he come to the home as she would not be able to see to the meal and manage an inspection visit. The other visitor was asked to make another appointment. Care staff reported that one of the residents was unwell and needed the G.P. There was a lot of activity in the home and it was evident that the acting manager was trying to cover several tasks. The owner arrived and decided to order a meal from the local chip shop so that the deputy could focus on our visit. Care Homes for Older People Page 30 of 41 Evidence: The acting care manager told us she has seventeen years of care experience. She told us she has had no periodic training since our last visit. She said the care manager post is being recruited too. She said that when the care manager left there was no one but her to act up which she has done since February. She acknowledged that by then lots of the management tasks had slipped. She told us that recently she has had more time in the office to undertake some of the managerial tasks but recognised that standards were not acceptable. She told us she has not had formal supervision and has at times to cover shifts when short staffed. The acting manager told us that there had been a significant staffing problem but that five new staff had been recruited. However as a result of staff shortages and the care manager post being vacant she had little time to undertake management tasks. During the course of our visit we noted a number of significant concerns about many aspects of the practice. There were a number of notifications outstanding. Some people had accidents resulting in injuries and broken bones we had not been notified about these. There had been incidents where staff had been injured we had not been notified about these. Previous sections in this report show there is poor monitoring of health concerns. Advice provided by the visiting matron for pressure relief had not been followed which leaves the person at risk of further health complications. We found that the monitoring of food and fluid intake was not occurring this could mean people are at risk of poor nutrition or dehydration. The AQAA tells us that nutritional screening is not applicable but the files for the people we looked at show that some are at risk of weight loss and or poor nutrition. These people did not have a risk management plan in place to show how their fluid and nutrition is monitored and encouraged and there was no record maintained to show food or fluid is promoted consistently. This is very worrying and indicates staff does not have the skills or training or the systems in place to identify people at risk and devise a risk management plan. The lack of care plans and reviews further compromise the care people receive which means their needs are not met in a consistent manner. There is no evidence of in house monitoring of practices and this potentially leaves people at risk. There is Quality Assurance questionnaires hanging in the hall and on viewing some people have completed these. However we were told there is no system in place to capture this information or identify the action to ensure improved outcomes or feed it back. This was similar to our last inspection visit. This indicates that quality Care Homes for Older People Page 31 of 41 Evidence: assurance initiatives have little priority. The AQAA was not completed or returned prior to this inspection. A reminder letter was sent to the service. On the day of the visit the owner brought a hand written AQAA to us this was not dated. The quality of the AQAA is poor there are no concrete examples of what the service has done over the last 12 months. Their proposals reflect those in their previous AQAA which means they have not achieved their targets for the past two years. The practice does not reflect what they say they are doing in the AQAA. For instance they propose to concentrate on training needs but records show no one has had any training in 12 months. The AQAA does not tell us that the care manager has left or tell us the proposed interim management arrangements or the impact this has had on the home. The care planning and management of risk does not reflect what the AQAA tells us. The AQAA is vague and lacks details with many gaps throughout. It is poorly filled in with no targets set. It tells us that policies and procedures are up to date but staff could not find the safeguarding ones when asked. The AQAA tells us staff supervision is being completed. We found that none of the day staff has had formal supervision and the acting manager told us she has only had time to do supervision for the night staff. The AQAA tells us that all files are being reviewed but we saw and were told care plans were not in place that staff was working from pre assessment information. In their AQAA they proposed to increase the activities for people with dementia but we found no increase in this area. Staff has not had training in this area for some time and care plans do not reflect dementia care needs. The home lacks direction. Management tasks have slipped significantly and accountability is not clear. We looked at a sample of heath and safety documentation. This showed that the equipment used had been serviced and was safe for use. However the temperature probe for water temperature testing was broken and needed to be replaced. As highlighted at the Environment section of this report a plan for achieving compliance with the environmental improvements highlighted in the recent environmental report is needed and a sufficiently experienced person must be identified to ensure systems are in place to maintain hygiene and food safety standards. We told the owner and acting manager that we have significant concerns about many aspects of their practice. For instance the poor quality of assessment care planning and risk management processes. We are concerned about the lack of notifications of accidents and aggression which means we cannot be sure these are managed appropriately and people are kept safe. We are concerned that the home has no Care Homes for Older People Page 32 of 41 Evidence: person with the necessary managerial skills and experience to manager the home. There is no one discharging the responsibility for the home and we cannot be confident that the assessed needs of people are being met. The owner told us he is trying to recruit an experienced manager. He acknowledged our concerns about the running of the home and the evidence to support our concerns. Care Homes for Older People Page 33 of 41 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 34 of 41 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Pre admission assessments must be thorough and include all the details of needs and risks and be kept under review. This is to ensure that the service can identify and meet the needs of the person and assure the person their needs can be met. 30/06/2010 2 7 12 To ensure that each person 30/07/2010 has a care plan. That health care assessments and risk assessments include all of each persons assessed needs. That these are updated to accurately reflect all changes to health and needs. To ensure each person receives the care and healthcare they need to ensure their health and Care Homes for Older People Page 35 of 41 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action well being is properly provided for at all times. 3 8 12 To ensure that people with 30/07/2010 poor nutritional intake and or weight loss identified and monitored using a recognised screening tool as frequently as required by their risk assessment and care plan. This will ensure that staff take required actions to promote the health and well being of individuals. 4 8 12 To ensure that care records such as food and fluid balance charts and pressure relief charts are maintained. The care provided is appropriately recorded and monitored and updated. This is to ensure the health and well being of people is maintained. 5 9 13 To ensure that all staff who administer medication are trained and assessed as competent to administer medication. This is to ensure that the people who use the service are safeguarded. 30/07/2010 30/07/2010 Care Homes for Older People Page 36 of 41 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 6 18 13 All staff must receive appropriate safeguarding training and be provided with safeguarding multi agency procedures. Procedures to protect vulnerable people must be implemented and followed diligently at all times. This is to safeguard all persons living at the home from risks of harm. 30/07/2010 7 27 12 To demonstrate that the 30/07/2010 number of staff on duty are skilled and trained and in sufficient numbers to meet the needs of each person using the service. This is to ensure that the health, well being and safety of people living at the home can be assured at all times. 8 31 8 The proprietor must ensure 30/07/2010 a manager is registered with CQC. This is to ensure effective leadership and management systems are implemented in the home to safeguard people. 9 33 24 To implement effective quality monitoring systems which demonstrate that positive quality outcomes 30/07/2010 Care Homes for Older People Page 37 of 41 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action are consistently achieved for all persons living at the home. This is to safeguard the health and well being of people living at the home. 10 37 37 To ensure notifications are 25/06/2010 submitted to the Care Quality Commission of any incident that has affected the health, safety or wellbeing of the people at the care home without delay. This is to safeguard the health, well being and safety of people living at the home. 11 38 13 Management systems must 25/06/2010 be implemented to ensure safe working practices including the provision of a first aider. The testing and recording of safe water temperatures. Food safety records and checks must be carried out. Safe working practices must be consistently followed and documented. This is to safeguard the health, well being and safety of people living at the home Care Homes for Older People Page 38 of 41 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 People should be provided with up to date information about the services the home provides to help them make an informed to choice. Good quality training should be provided to enable staff to develop and be aware of current good practice. People with specialist needs who live in the service may receive very poor quality of care through lack of trained and knowledgeable staff The home should arrange training on health care topics that relate to the health care needs of the people. In particular where people refuse care staff need to recognise this and develop a management plan so that the needs of the person are not neglected. Personal preferences should be accurately recorded for each person and daily routines should be flexible to meet each persons choices. There needs to be a regular meeting for people using the service to ensure that they can contribute towards the day to day running of the home. People should receive a nutritious diet which is suited to individual assessed and recorded requirements. Staff should receive training in regard to the Mental Capacity Act 2007. Deprivation of Liberty protocols and guidance. Thus ensuring the safety of the people using the service. A plan for achieving compliance with the environmental improvements highlighted in the recent environmental report is produced and followed. To identify a sufficiently experienced person to ensure systems are in place to maintain hygiene and food sfaety standards. To ensure that a review is undertaken identifying all staff are enrolled on NVQ Level 2 training. Staff should receive training in regard to the Mental Capacity Act 2007, Deprivation of Liberty protocols and guidance, and Adult Protection Safeguarding. Thus ensuring the safety of the people using the service. Staff should receive a minimum of three paid days training 2 4 3 10 4 12 5 14 6 7 15 18 8 19 9 26 10 11 28 30 12 30 Care Homes for Older People Page 39 of 41 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations per year, including in house training, and have an individual training and development assessment and profile. Thus ensuring that staff receive training appropriate to their role and responsibilities. 13 30 Staff should have appropriate mandatory update and refresher training according to their role and responsibilities. A structured staff supervision system should be resumed to ensure all staff receive formal supervision at least six times each year to provide them with support and development to meet the needs of people using the service. 14 36 Care Homes for Older People Page 40 of 41 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. 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