CARE HOMES FOR OLDER PEOPLE
Castlemount 54 Manygates Lane Sandal West Yorks WF2 7DG Lead Inspector
Susan Vardaxi Unannounced Inspection 28th October 2005 09:24 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 Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Castlemount Address 54 Manygates Lane Sandal West Yorks WF2 7DG 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) 01924 251127 Mr Abbass Bagheri Satari Mrs Julie Ann Satari Ms Amanda Machin Care Home 15 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (15), Old age, of places not falling within any other category (15) Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: Castle Mount Care Home is a four storey grade 2 listed building situated in Sandal on the outskirts of Wakefield. The home provides care and accommodation for 15 older people over the age of 65 years who may have past or present mental health problems. The building is set back in its own grounds, some car parking space is available at the front of the home. Due to the steep steps leading up to the front door the home is only accessible by wheechair from the side door leading onto a side road. The home has nine single and three double bedrooms, ensuite facilites are not provided however communal toilets and bathing facilities are avaiable on all floors which are accessible by chair lift. A large entrance hall leads to the two spacious communal lounges and dining area. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection completed on 28th October 2005 over a period of eight hours. The inspection process included talking with service users, staff on duty and the provider, a walk in the grounds and checking some records. Eleven service users were living at the home. What the service does well: What has improved since the last inspection?
One of the providers has been visiting the home to support the manager and improvements in the service have been made. Through discussions with her it was established that she is involved with service users during these visits. A senior carer said she had been appointed as the home’s activities organisers and she had encouraged service users to make greetings cards, which went on sale at a Summer Fayre earlier in the year. The carer was very enthusiastic about her new role. A great improvement has been made to the general condition of the external ground and gardens. Some carpets have been replaced in hallways. The manager said she was meeting with a representative of an emergency call system company to improve the system so that staff can hear calls for assistance when they are working in the basement of the home. The provider said the stair lifts are to be replaced by a shaft lift. More attention appeared to have been given to service users’ personal hygiene needs. Requirements made at the last inspection in respect of Health and Safety concerns have been dealt with, running hot water temperatures were not checked on this visit. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 6 Privacy is now being given to service users’ care plans, which were seen to be stored in a locked cupboard. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3, Pre admission procedures appear to have been completed appropriately however the service users guide still needs to be developed. EVIDENCE: A discussion with one of the providers identified that the service users’ guide had not been updated as required at the last inspection. A service user‘s file seen, included contracts and a social care assessment had been completed. Intermediate care is not provided at the home. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, There has been some improvement in the standard of care planning since the last inspection, however further development is still required of all records held in respect of service users to ensure that all needs are identified and met appropriately and recorded. EVIDENCE: Service users’ files seen showed that they had care plans, and a service user had been involved in the care planning on admission. It was pleasing to see that a care plan had been completed for a service user having respite care. However some information on a care plan had not been updated when no further action in respect of their fractured arm was needed. Also the care plan did not include how the service user should be assisted to transfer or for prevention of pressure sores following a fractured femur, this accident had not been reported to the Commission. There was no evidence on a care plan to show how to deal with outbursts of aggressive behaviour or agitation. An accident form seen, recorded that the service user was agitated and was “found on the floor by a carer who had left them in a chair to go for the assistance of another carer”, there was no evidence of this incident in the daily records.
Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 10 Hospital discharge letters for the attention of the service user’s GP and district nurse were seen on the service user’s file. The provider said that she is involved with service users during her visits, she said she had taken service users to the GP surgery for blood tests and discussed concerns in respect of a service user’s health further with the GP when required. There was no evidence to show that nutritional assessments had been completed and staff said that it was not always possible to weigh some service users on the weighing scales now in use. A service user’s care plan seen did not show what action was needed to prevent incontinence and according to the records, the Chiropodist had not visited since October 2004. However on their personal allowances records the chiropodist had signed the records to confirm he had visited and had been paid in February and May 2005. Service users’ preferences to get up and go to bed were seen recorded on files checked. The medication records seen had been generally well maintained. However one record showed an error in the number of tablets received from the pharmacist and the number of staff signatures on the medications sheet. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Opportunities for service users to pursue activities have been provided. The provision of meals appears to be satisfactory, however the “banter” between staff when assisting service users to eat does not help to create a relaxed and pleasant environment for service users to eat in. EVIDENCE: A carer spoken with said that they had been nominated as the activities person and allocated funds for this. The carer said greetings cards had been made by some service users and some had been sold at a Summer Fayre. She was very enthusiastic about her new role and said that she had plans to introduce more activities in the future. The service users were joined for lunch, the meal was well cooked and presented. Staff were observed assisting some service users to eat, they sat down at the table with the service user. However there was a lot of banter between some staff in the dining room rather than concentrating on the task of assisting or speaking to service users. One service user was not given the opportunity to empty their mouth before more food was offered. This was discussed with the provider who said that staff could have been affected by being observed. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 There was evidence at this inspection to show that complaints are now being dealt with appropriately. EVIDENCE: The providers had not responded to a complaint passed to them by the Commission for investigation in January 2005 this has now been received and is currently being processed. The home’s complaints records seen showed one complaint had been made and had been dealt with and action taken. The provider said that seven service users had used the postal voting method at the last election. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 26 The general standard of cleanliness, décor and maintenance provides a pleasant and comfortable living environment for service users. The external environment is pleasant, however free access into the garden area is not possible due to safety issues. EVIDENCE: The communal areas seen were decorated to a good standard. A maintenance person is employed and the improvement he has made to the condition of the gardens and grounds is commendable. Staff said that flower baskets had been on display outside the home during the summer months and had looked very attractive. The two recommendations made in the fire officer’s report were discussed with the provider who said she had made arrangements for the work required to be completed the following week. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 14 The provider said that she was due to meet with an emergency call system representative to discuss methods to ensure staff could hear the emergency call system when working in the basement. Some carpet replacement had been completed; a carer spoken with said that service users had been involved in the choice of colour. The provider said that she is currently looking to replace the stair lifts with a shaft lift. The laundry room was seen to be clean and tidy, and no unpleasant odours were observed throughout the inspection. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Recruitment procedures are satisfactory. Care staffing levels have not always been adequate. EVIDENCE: A senior carer, two care assistants, a domestic assistant and a cook were on duty during the inspection. Staff rosters seen, showed shortfalls in staffing levels during October 2005 on occasions falling below three carers on duty. There had also been occasions when a member of staff had worked continually throughout the day and night to provide cover for sickness and vacancies. Staffing arrangements were discussed fully with the provider at the time of the inspection who said that the day carers provide personal care only and domestic assistants make beds, put service users clothing away etc. However carers do have to prepare and serve the evening meal. A newly recruited carer’s records seen showed that a satisfactory CRB check had been received on 11th October 2005 and they had not started work until 14th October 2005. Two references and a work experience reference had been obtained. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 Some service users’ financial records do not confirm that their personal allowance is being paid to them. EVIDENCE: The registered manager has given notice to terminate her employment and arrangements for a new manager to replace her have been made. A staff meeting was being held after the inspection to introduce the new manager and the meeting was well attended. One of the providers is now undertaking monthly-unannounced visits to the home and providing the Commission with her visit reports. Some records of monies held on behalf of service users were seen; the cash balances were not checked. he records showed that receipts are obtained and withdrawals and deposits have been recorded. Some service users appeared to be in arrears to the home where money had been used from the home’s petty
Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 17 cash to pay for chiropody, hairdressing etc. This was discussed with the provider. A staff file seen showed evidence of first aid, manual handling, health and safety and fire training during 2005. However the fire records showed that not all staff have had regular fire training. There were no other health and safety concerns seen during this visit. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 18 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 1 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 3 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X X 3 Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 5(1-3) Requirement Timescale for action 31/12/05 2 OP7 15(1) 3 OP8 13(1)(b) That an up to date service user guide be made available to all existing and prospective service users and/or their representatives, which meets current legislation. Previous timescale of 30th June 2005 not met Care plans must be generated 28/10/05 from an assessment of residents needs and residents/ representatives involved. Previous timescale of 25 April 2005 not met. Nutritional assessments must be 30/11/05 completed for all residents and an appropriate weighing facility provided. Previous timescale of 30 June 2005 not met Written information received on service users discharge from hosptial must be passed to their GP District nurse immediately on receipt. Advocacy arrangements must be made when residents are unable to make informed choices
DS0000006172.V264413.R01.S.doc 12(1)(a) 5 OP14 12(2) 12 (4)(a) 28/10/05 Castlemount Version 5.0 Page 20 6 OP27 18(1)(a) 7 OP32 37(1)(a-f) (2) 8 OP38 23(4) regarding the handling of their finances. Care staffing levels must be provided and maintained to numbers that ensure service users are safe and their needs met. The registered person must ensure that the Commission are notified all occurrences that occur in the home in respect of this regulation. The fire risk assessment must be reviewed. Previous timescale of 25th April 2005 not met. The registered person must confirm in writing to the Commission and the fire service when the recommendations made in the fire officer’s report have been completed. 28/10/05 28/10/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP10 OP15 Good Practice Recommendations The daily records should include details of how service users’ needs have been met “Banter” between staff should not affect the delivery of care or service users’ dignity when assisting service users. Staff should be trained in how to assist service users who need assistance to eat their meals. Castlemount DS0000006172.V264413.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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