Inspection on 09/11/06 for Castlefort Grange

This inspection was carried out on 9th November 2006.

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

Other inspections for this house

Castlefort Grange 30/03/10

Castlefort Grange 07/05/09

Castlefort Grange 16/05/07

Castlefort Grange 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 Maggie Bennett Key Unannounced Inspection 9th November 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Castlefort Grange DS0000020808.V319277.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.V319277.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 (7), Old age, not falling within any registration, with number other category (23) of places Castlefort Grange DS0000020808.V319277.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 7 (seven) beds may be used for (DE) Dementia or (OP) Older People 10th May 2006 Date of last inspection Brief Description of the Service: Castlefort Grange is registered to care for 23 older people, 7 of whom may have been diagnosed with dementia. The home is situated in the Walsall Wood area of Walsall and is within easy reach of Brownhills and Walsall. There are shops nearby, but not within walking distance for the majority of service users. The home has undergone major building work to increase its size and provide new rooms. Several of the existing bedrooms have been extended to provide an en suite toilet, the lounge has been extended and a conservatory added. In total there are 17 single rooms and 3 double rooms. There is a separate dining room. The home has a large garden. The home’s current scale of charges ranges from £327.00 to £375.00 per week. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between 09.00 a.m. and 7.40 p.m. All the key standards of the National Minimum Standards were assessed on this occasion. The home was previously inspected on 11th May 2006 when 26 statutory requirements were made. 14 of those requirements were found to have been met, or were in the process of being met. A further 9 statutory requirements were made on this occasion. At the time of this inspection there were 15 service users living at Castlefort Grange, 7 of whom had been diagnosed with dementia. Several service users were spoken to during the course of the day and 2 visiting relatives were seen. Discussion also took place with the Registered Manager, Deputy Manager, Registered Provider and 3 members of staff. The assessment information and care plans of 7 service users was seen in order to inspect assessment and care planning practice. Staff files were seen in order to assess recruitment practice and training. Various other documents were seen so that health and safety procedures and practice could be inspected. A tour took place of the building. What the service does well: What has improved since the last inspection? Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 6 The home has improved the way its gathers assessment information about prospective service users. This has meant that they are more aware of the needs of the service users. The majority of the staff have taken part in Dementia Care training and this has clearly helped them to understand and assist those service users with dementia. The medication cabinet has been cleaned and tidied since the last inspection and was found to be in good order on this occasion. An appropriate system for recording complaints is now in place (although no complaints have been made since the last inspection). Although there remains some outstanding work, several improvements have been made to the physical environment of the home, including re-decoration in some bedrooms and the provision of radiator covers. Copies of certificates to verify staff training are now mostly available in files, although there is still a need to provide an individual training and development assessment and profile for each member of staff (see below). These improvements mean that the home have improved on its overall rating since the last inspection. What they could do better: Although the assessment practice has improved, the Registered Manager must write to the prospective service user following assessment confirming that the home is able to meet their needs. There is a satisfactory care planning system in place, but this is not being used to full effect and regularly updated to reflect changing needs. There is no evidence that service users are involved in drawing up their care plans. There is little evidence of an improvement in the provision of social care activities and service users’ interests, hobbies and aspirations have not been recorded. Some of the staff felt that they did not have enough materials and equipment to carry out activities and that this was hampering progress in this area. There are no specialist activities provided for those service users with dementia. Although the food provided is of very good quality, the home should provide a distinct choice for the main meal of the day. There are still some areas in the physical environment which need attention and these are listed in the Environment Section. Although care staff levels were adequate on the day of the inspection, it was found that cleaning staff were not routinely employed at weekends. A cleaner must be employed on 7 days a week. There are still some shortfalls with recruitment practice, application forms did not contain a full employment history, not all new starters had provided 2 written references and a risk assessment had not been completed for staff commencing work on the basis of a POVA First check. Induction training must be provided to Skills for Care specifications and all staff files must contain an individual training and development assessment and Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 7 profile. Staff files must contain all those documents required by Regulation. Although the home has begun to seek the views of relatives of service users, little progress has been made on the production of an annual development plan, based on a systematic cycle of planning, reflecting aims and outcomes for service users. 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.V319277.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4. Standard 6 is not applicable, as the home does not offer intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users are properly assessed before they move to Castlefort Grange. This assessment goes some way towards ensuring that the home is able to meet the person’s needs. Although the home are carrying out proper assessments, they must confirm the findings of their assessment to the service user in writing. The home is able to meet the specialist needs of its service users with dementia and provides appropriate training for staff. EVIDENCE: The care plans of the 2 most recently admitted service users were seen in order to inspect assessment practice at Castlefort Grange. Both service users had been referred through Care Management and the service users’ social workers had forwarded a copy of their assessment and care plan to the home prior to the person being admitted. One service user lived locally and the Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 10 Registered Manager of Castlefort Grange had visited this person and additionally completed her own assessment. This assessment covered all those areas detailed in Standard 3.3 of the National Minimum Standards. The second service user lived a considerable distance away and it was not possible for the Manager to visit prior to the person moving, but full information was obtained from the hospital where the person was a patient and the person also visited the home prior to deciding whether or not to move in. Following assessment, the Registered Manager must write to the prospective service user confirming that the home will be able to meet their needs. There was no evidence that this had been done in these 2 cases. The assessment information had been used to develop a plan of care for daily living (see Standard 7 below). Both of the service users recently admitted had been diagnosed with dementia. The home now has 7 people who have specific needs because of dementia. Several staff have undertaken appropriate training in this area and staff feel that this has been of great benefit in helping their understanding the needs of these service users. It remains a condition of the registration of the home that the Registered Manager successfully complete Dementia Mapping Training and it is understood this training is currently being sort. Although Standard 2 was not assessed on this occasion, it was noted that there were Contracts in the files of the service users, but these had not been signed or dated. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a good system in place for care planning, but at present the home is not utilising this to the full with the result that not all care plans are regularly reviewed and updated. Service users are not involved in developing and reviewing their care plans. The healthcare needs of service users are generally well met, but would be better ensured if they were clearly documented in care plans. Medication is well administered and recorded. Service users’ rights to respect and privacy are upheld. EVIDENCE: 7 Care Plans were seen during the inspection. These included care plans of service users with dementia and of a service user with high levels of dependency because of physical frailty. The home have devised a good system for care planning, with files divided into different sections and an index at the front. Not all the areas had been completed and the various sections, such as “G.P. and nurse visits” did not always contain the details the heading Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 12 said they did. This is unfortunate, as if completed, the care plans would be a good document and provide staff with the information they need to ensure that the health, personal and social care needs of the service users are met. Daily records are also kept and these give a clear record of any recent significant events. In some, but not all, of the care plans there was evidence of monthly reviews. All contained a risk assessment, but as with the care plans, it could not be evidenced that these were reviewed on a regular basis. There was nothing in the care plans seen to indicate that the service user had been involved in the preparation of the care plan and had signed their agreement to it. All of the files seen contained a pressure sore risk assessment and these had been regularly reviewed. There are no service users with pressure sores at the home at present. Pressure relieving equipment is available via the District Nurses when needed. There is a “Medical Profile” form on the care plans, but these had not been completed in all the cases seen. One person had been fitted with a catheter, but there were no instructions on the care plan as to how the catheter care was to be managed. Files showed that advice is sought with regard to continence promotion and that the home are regularly visited by other healthcare professionals, such as district nurses, community psychiatric nurses, chiropodists, dentists and opticians. It was observed during the day that both the Manager and Deputy Manager had a sound knowledge of the healthcare needs of their service users and that they had sought advice when needed. Nutritional screening is undertaken at assessment and if there is a concern about a service user’s nutritional intake, a daily food and fluid intake chart is put into operation. Service users are regularly weighed and a record kept. The home’s system of recording G.P. and District Nurse visits is a good one and gives a clear picture of why the G.P. was called and what intervention has been put into place. The overall picture of care planning at Castlefort Grange is one of continuing improvement. The home have got a good system in place, but they do need to utilise this and ensure that plans are up to date and regularly reviewed. They also need to make sure that plans are filed correctly and in date order for ease of reference. There is a policy in place for the receipt, recording, storage, handling, administration and disposal of medicines. None of the current service users take charge of their own medication, apart from some creams, which are kept in individual rooms. All service users have a lockable facility in which to keep medication if they wish to self-administer. There are no service users at the home at present who are prescribed controlled drugs. The home are advised, however, to obtain suitable storage and recording systems for controlled drugs Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 13 should the need arise in the future. All those staff who administer medication have received accredited medication training. A random sample of the medication and accompanying records were seen during the inspection and there were no discrepancies. Records were also seen of the return of any unused medication to the Pharmacist. The Deputy Manager and the Pharmacist carry out regular audits of the medication administration. It was noted that staff were carrying “nomad” boxes to and fro to service users while administering medication and it is strongly recommended that the home purchase a medication trolley. It is recommended that the home develop a “homely remedies” policy. All of the current service users at Castlefort Grange have their own rooms and therefore all personal care giving takes place in private. The home have a portable hand-held telephone, which service users may take to their rooms to receive and make calls in private, if they wish. Staff are instructed during their induction training on the importance of treating service users with respect. Records of induction training are, however, poor (see Standard 30). Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to exercise choice at the home with regard to the routines of daily living and activities. Although it is clear that the management and staff are keen to improve the provision of leisure and recreational activities, very little progress has been made in this area, particularly with regard to daily activities within the home. Care plans do not reflect service users’ wishes in this area. The meals in the home are of excellent quality and are very much enjoyed. The home needs to be clearer, however, about offering choices at mealtimes. EVIDENCE: Service users spoken to during the inspection confirmed that they were able to exercise choice with regard to whether or not they joined in with any social activities at the home. Several also said that they could get up and go to bed whenever they wished. Of the care plans seen, the section with regard to service users’ interests and hobbies was not completed in most cases. One care plan indicated that the last time the service user had taken part in an Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 15 activity was on the 20th July 2006. Records show that a light exercise class is held regularly, but other activities in the home appear to be arranged on an “ad hoc” basis. For those service users who wish to participate, a representative of the local Church visits each month and conducts a service. Some of the staff felt that more could be done to provide appropriate activities, they said that they lacked equipment and materials for craft work and prizes for bingo. There were, however, plans for a Christmas Fair and Christmas Party. There are no specialist activities provided for service users with dementia. There has been very little improvement in this area since the last inspection. The home must provide a regular programme of activities, designed to meet the needs of the service users. Up to date information about activities must be circulated to the service users. Service users are able to see their visitors at any reasonable time and to see them in private if they wish. There are no restrictions. Service users are able to take charge of their personal finances if they wish, although none choose to do so at present. All have been informed in writing of their right of access to their personal records. All of the service users spoken to at the inspection said that the food provided at the home was of very good quality. Service users did not seem to be aware that there was a choice for the main meal, but the Manager stated that there was always an alternative for those who didn’t like what was on the menu and that staff knew the service users well and were aware of their likes and dislikes. The main meal of the day is advertised on a blackboard in the hall. This is shortly to be replaced with a larger white board, which will be more noticeable. Three main meals are provided, including a cooked breakfast if service users wish. Drinks and snacks are provided in between meals and at supper-time. Menus seen show that a variety of nutritious foods are provided. Puddings and cakes are often home made. It continues, however, to be a strong recommendation that a distinct choice is offered for the main meal of the day and that this is advertised on the menu board and discussed with the service users. Special diets are provided if needed and currently some service users have a diabetic diet. The meal on the day of the inspection, tomato soup, cottage pie with fresh vegetables followed by sponge pudding and custard, was very much enjoyed. The kitchen was clean and in good order. Fridge and freezer temperatures and cooked food temperatures and taken daily and recorded. The home have sought advice from the Health Authority nutrition advisor. There were ample supplies of food in the home, including fresh fruit and vegetables. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a suitable Complaints Procedure in place and several of the service users spoken during the inspection said that they would know who to complain to and felt that they would be listened to. The home’s Adult Protection Procedure needs to be updated so that it is in line with the Local Authority Procedure. The management and staff of the home are aware of their responsibilities with regard to the Protection of Vulnerable Adults. EVIDENCE: The home have a satisfactory complaints procedure in place and a copy of this is provided in the Service Users’ Guide. Service users spoken to during the inspection said that they would know who to speak to if they had a complaint. In addition to a book in which to record Complaints, the home keep a book in the hallway and encourage service users and their relatives to record any concerns they may have. No complaints have been received by the home or by the Commission since the last inspection. The home have their own Adult Protection Policy and Procedure in place, but this has remained unchanged since the last inspection and is not in line with the Walsall Social Services Procedure. The Registered Manager now has a copy of the recently reviewed Walsall Social Services Procedure and will be Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 17 updating the Castlefort Grange procedure to ensure that it is in line with this document and the Department of Health document, “No Secrets”. There have been no allegations of abuse made since the last inspection. The Registered Manager, Deputy Manager and staff spoken to during the inspection are aware of their responsibilities with regard to the Protection of Vulnerable People. The majority of the staff at the home have taken part in Adult Protection Training. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There continue to be improvements to the physical environment. These improvements are making Castlefort Grange a safer and more comfortable home for the service users. The pace of the improvements is, however, frustrating for some of the staff and the “clutter” created by the ongoing work is taking up storage space in some areas. The home is clean and there are good standards of hygiene. EVIDENCE: There have been a number of improvements to the physical environment of Castlefort Grange since the last inspection. The Registered Provider states that he operates a programme of routine maintenance and that decoration is renewed at regular intervals. There is a pleasant garden to the rear of the property, which has been enjoyed by service users during the summer months. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 19 The Registered Provider is aware that several doors do not close firmly into their rebates and states that this is an issue that he is currently dealing with. Castlefort Grange has one large lounge, which can be divided if needed for separate activities and a dining room, with conservatory. The following are recommendations with regard to the communal living areas: that dining room chairs be replaced (the current ones are have no arms and are not easily manoeuvred); that wheelchairs be removed from the recess area in the lounge, so that there is more space for storage (particularly for materials for social care activities); that additional small tables be provided for service users to put their drinks and snacks on. All the bedrooms were seen during the inspection. The carpet to one room (number notified to Registered Provider) needs cleaning (it may be that following consultation with the service user and their family, suitable washable floor covering is provided). In some of the en suite bathrooms unsightly pipework needs to be boxed in. While Room 18 is used as a storeroom it must be locked. It was good to note that radiators in bedrooms have now been covered. Bricks and rubbish have still not been removed from outside Room 5, although this room is currently unoccupied. Some rooms were in need of brightening up by the provision of pictures and ornaments. It is recommended that relatives be requested to assist service users to personalise rooms to their taste and that where this cannot be achieved, the home consult with the service users about what they would like in their rooms. The separate toilet on the first floor needs re-decorating and the bathroom needs attention, particularly the bath panel, which had fallen off at the time of the inspection. The laundry has been fitted with an air conditioning unit and the high temperatures in the room have been abated to some degree. A new sink unit has been fitted in this room. The premises were clean and free of offensive odours at the time of the inspection. The washing machine has a sluicing facility and “dissolvo” bags are used for foul laundry. Staff spoken to during the inspection felt that there was still a need to “de clutter” at the home. They also said that there was sometimes frustration when it took a long time for “little jobs” (such as the fixing of toilet seats) to get done. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At the time of the inspection there were sufficient care staff on duty to meet the needs of the service users. A cleaner must be employed at weekends to ensure that the home maintains its high standards of cleanliness throughout the week. Despite not having a training budget, the Registered Manager is proactive in obtaining a good deal of appropriate training for staff. Staff are achieving well in the National Vocational Qualification and Dementia Care training and this is of benefit to the service users. There are still gaps in recruitment practice and this could have the potential to place service users at risk. Induction training for new staff needs to be improved, as it currently does not meet Skills for Care specifications. EVIDENCE: At the time of the inspection there were 15 service users living at Castlefort Grange and there were sufficient staff on duty to meet the needs of the service users. During the morning shift there are 3 care staff on duty, in addition to the cook and cleaners. In the afternoon/evening there are also 3 care staff on duty, 1 of whom prepares the tea-time meal. Overnight there are 2 waking night staff. The Manager’s hours are supernumerary. These staffing levels meet the needs of the current group of service users, 7 of whom have dementia and 1 of whom has a high level of dependency because of physical Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 21 frailty. The Registered Provider and Registered Manager are aware that should numbers increase, particularly numbers of people with dementia, the ratios of care staff to service users will need to be re-assessed. Housekeeping staff are employed in sufficient numbers during the week, but at weekends a cleaner is employed on alternate Saturdays only. This is not sufficient, particularly bearing in mind the needs of the service users and it is, therefore, a requirement that a cleaner be employed on 7 days a week. The home still have a vacancy for a tea-time and weekend cook and are actively seeking to fill this. 8 of the current group of care staff have achieved the NVQ2 award and the remaining have been enrolled to commence this training in the near future. The home, therefore, has 50 of its staff trained to NVQ2. There are no agency staff or trainees employed. The staff files of newly recruited staff were inspected in order to assess recruitment practice. Both of the staff concerned had completed application forms, but the forms did not contain a full employment history. The Registered Manager stated that the home had recently devised a new application form, which ensured that a fully employment history was obtained, but old forms had been used for these 2 members of staff. One file contained 2 written references, but the other only contained 1 written reference. Both members of staff had been started on the basis of a POVA 1st check (prior to the satisfactory Criminal Records Bureau check being received) and confirmation of this was seen. The home had not, however, carried out a risk assessment, which is required in these circumstances. The Registered Manager states that staff are given copies of the General Social Care Council Code of Conduct. There was nothing in writing in individual files, however, to verify this. The staff receive statements of their terms and conditions. There are no volunteers employed at the home. The Registered Manager is not given a budget for training, but obtains as much relevant training as possible through local resources. This has included training in Dementia Care and Adult Protection. For details of staff training in the mandatory health and safety areas see Standard 38. In some of the staff files seen there were details of the training undertaken by the individual. This needs to be developed so that all staff have an individual training and development assessment and profile. There was a record of the first day and first week’s induction training in each of the files of the newly recruited staff. There was, however, no record of induction training during the first six weeks of appointment. Induction training to Skills for Care specifications must take place during the first six weeks. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 22 Staff files seen did still not contain all those documents required by the Care Homes Regulations. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is qualified and very experienced and is committed to providing the service users with a good quality of life. The views of service users’ relatives have been obtained, but the home needs to seek the views of all its stakeholders (service users and all visiting professionals). The resulting information should be used to measure success in meeting the home’s aims, objectives and statement of purpose and to ensure that the home is run in the best interests of the service users. Service users’ monies are kept securely and their financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted by the home’s policies and procedures. Appropriate risk assessments have been carried out, but this must include the external as well as internal premises. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager and Deputy Manager have both achieved the Registered Managers’ Award. They are experienced, liked and respected by service users, their relatives and staff. The Registered Provider spends a great deal of time at the time and also has a very good rapport with the service users. Both of the Managers have successfully completed Dementia Care training and are currently enquiring about commencing the Dementia Mapping training. Staff seen during the inspection felt that they were very well supported by the management of the home. One person said, of the Registered Manager: “Jean Riggs is absolutely wonderful, if it weren’t for her we wouldn’t have such a good staff team.” Questionnaires have been sent to all the service users’ families, requesting their views of the home. At the time of the inspection, these were the only views that had been obtained. The home needs to development this further, so that service users’ and all other stakeholders’ views (such as visiting Doctors, nurses and social workers) are sought. The resulting information needs to be collated so that the home can measure its success in meeting its aims, objectives and statement of purpose. The results of the surveys must be published and made available to current and prospective service users, their representatives and other interested parties. There must be an annual development plan in place, which reflects the aims and outcomes for service users. Service users’ meetings are held, the last one in September 2006, when Christmas arrangements and entertainment were discussed. The home looks after some monies on behalf of service users. In the majority of cases, relatives take charge of the personal allowances of the service users and hand this money over to the home for specific purchases, such as hairdressing. The Registered Person does act as Appointee for one service user, but this person now has their own Account and no monies are paid directly into the home’s account. A random sample of the monies and accompanying records were seen at the inspection and there were no discrepancies. The home’s training record shows that staff take part in training in the mandatory health and safety areas: moving and handling, fire safety, first aid, food hygiene and infection control. There has been some improvement in making sure that copies of certificates to verify training are available in staff files. As stated in the section on Staffing (above) each staff file must contain an individual training and development assessment and profile. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 25 Records seen show that fire alarm tests, emergency lighting tests and fire drills are carried out at the required intervals. The fire fighting equipment is regularly checked and maintained. There is a fire risk assessment in place. All hazardous substances are stored securely and the home keeps an analysis of all products used. Evidence was seen of the regular maintenance of the boiler and gas central heating system, the electrical systems, electrical equipment and of the testing of the water supply and cleaning the water system. The Registered Manager has carried out an internal risk assessment for safe working practice topics. A risk assessment must also be carried out with regard to external areas, such as the garden and storage areas. All accidents, injuries and incidents of illness or communicable disease are recorded and reported to the Commission. As stated in Standard 30 (above) the Registered Manager must ensure that all new staff receive induction training to Skills for Care specifications on all safe working practice topics. Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 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 2 2 X X X X 2 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(d) Requirement Timescale for action 30/11/06 2. OP7 3. OP7 4. OP7 5. OP8 6. OP12 Following assessment, the Registered Manager must write to the service user confirming that the home is able to meet their needs. 15(1) There must be an up to date plan of care in place which sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. 15(2)(b)(c The service users’ care plans ) must be reviewed at least once a month and updated to reflect changing needs. 15(1) Where possible the service user must be involved in drawing up their care plan and sign to verify their agreement of the plan. 15(1) Where service users have specific medical needs, i.e. such as catheter management, the care plan must give clear details as to how these needs are to be managed in the home. 15(1) Service users’ interests must be recorded on their care plan and DS0000020808.V319277.R01.S.doc 31/12/06 30/11/06 30/11/06 30/11/06 31/12/06 Castlefort Grange Version 5.2 Page 28 7. 8. OP12 OP18 12(4)(b). 12(1)(a) 9. OP19 23(4) 10. OP24 16(2)(c) 11. OP21 23(2)(b) 12. OP27 18(1)(a) 13. OP29 19 there must be evidence that they are given opportunities for stimulation through leisure and recreational activities in and outside the home. Up to date information about planned activities must be circulated to the service users. (Previous timescale of 30/06/06 not met). Specialist activities must be provided for those service users who have dementia. The home must update its Adult Protection Procedure to ensure that it is in line with the Department of Health guidance No Secrets and the Local Authority Procedure. (Previous timescales of 31/07/05, 31/11/05, 30/04/06 and 30/06/06 not met). It is acknowledged that this is currently being addressed. The registered person must ensure that all the requirements of the Fire Officer are met. All fire doors must close firmly into the rebates. (Previous timescale of 30/06/06 not met). All those areas listed as needing attention in individual rooms must be dealt with. (See Standard 24). The separate toilet on the first floor must be re-decorated. The bath panel to the bathroom on the first floor must be repaired. Domestic staff must be employed in sufficient numbers to ensure that the home is maintained in a clean and hygienic state. A cleaner must be employed on 7 days a week. Application forms for new employees must contain a full employment history and any DS0000020808.V319277.R01.S.doc 31/12/06 31/01/07 31/01/07 31/12/06 30/11/06 30/11/06 30/11/06 Castlefort Grange Version 5.2 Page 29 14. OP29 15. OP29 16. OP29 17. 18. OP30 OP30 19. OP29 20. OP33 gaps must be explored by the Registered Manager. Schedule Two written references must be 2 obtained before appointing a Regulation new member of staff. (Previous 7, 9, 19. timescale of 10/05/06 not met). Care If staff are employed on the Standards basis of a POVA First check, the Act. home must also carry out a risk assessment and ensure that the person employed is supervised at all times. (Previous timescale of 10/05/06 not met). Care All staff must be given copies of Standards the General Social Care Council Act. Code of Conduct and must sign to verify receipt. 18(1)(c) All staff must have an individual training and development assessment and profile. 18(1)(c) All new members of staff must receive induction training to Skills for Care specifications within 6 weeks of their appointment, including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. (Previous timescale of 31/05/06 not met). Schedule Staff files must contain all those 2 Regs. 7, documents required by 9, 19. Regulation. (Previous timescale of 30/06/06 not met). 24 The home must produce an annual development plan, based on a systematic cycle of planning, reflecting aims and outcomes for service users. (Previous timescale of 31/07/06 not met). DS0000020808.V319277.R01.S.doc 30/11/06 30/11/06 30/11/06 31/12/06 30/11/06 30/11/06 31/01/07 Castlefort Grange Version 5.2 Page 30 21. OP38 12(1) The Registered Manager must provide a written statement of the policy, organisation and arrangements for maintaining safe working practices. Risk assessments must be carried out on safe working practice topics and these findings recorded. This must include external areas as well as the inside of the building. 31/01/07 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 OP9 OP15 OP20 Good Practice Recommendations It is strongly recommended that the home provide suitable storage and recording systems for controlled drugs. It is recommended that the home purchase a medicines’ trolley. It is strongly recommended that a distinct choice be offered for the main meal. The following recommendations are made with regard to the communal living areas: that dining room chairs be replaced (the current ones are have no arms and are not easily manoeuvred); that wheelchairs be removed from the recess area in the lounge, so that there is more space for storage (particularly for materials for social care activities); that additional small tables be provided for service users to put their drinks and snacks on. It is recommended that relatives be requested to assist service users to personalise rooms to their taste and that where this cannot be achieved, the home consult with the service users about what they would like in their rooms. It is strongly recommended that the home purchase a set of seated scales so that all the service users can be regularly weighed. 5. OP24 6. OP8 Castlefort Grange DS0000020808.V319277.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 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.V319277.R01.S.doc Version 5.2 Page 32 - 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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