Inspection on 09/05/06 for Castlemount

This inspection was carried out on 9th May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Castlemount 19/08/08

Castlemount 15/01/08

Castlemount 16/07/07

Castlemount 28/09/06

Castlemount 28/10/05

Castlemount 25/04/05

Castlemount 18/11/04

Castlemount 22/07/04

Castlemount 17/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Castlemount 54 Manygates Lane Sandal West Yorks WF2 7DG Lead Inspector Susan Vardaxi Key Inspection 9th May 2006 9.00am 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.V291223.R01.S.doc Version 5.1 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.V291223.R01.S.doc Version 5.1 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 MANAGER ONLY CastleMountRes@aol.com Mr Abbass Bagheri Satari Mrs Julie Ann Satari 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.V291223.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 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. A short distance walk from the home is needed to access the bus service running to Wakefield and Barnsley. 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 wheelchair from the side door leading onto a side road. The home has nine single and three double bedrooms, ensuite facilities are not provided however communal toilets and bathing facilities are available on all floors, which are accessible, by chair lift. A large entrance hall leads to the two spacious communal lounges and dining area. The provider makes information about the service to enquirers when initial enquiries are made. The fees charged in May 2006 were from £359 to £375; hairdressing chiropody and personal newspapers are charged in addition to the fees. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory inspection undertaken on Tuesday 9th May 2006 by two Regulation Inspectors. The manager had been notified of the inspection four days before the inspection visit. Since October 2005 an additional visit was made in January 2006 in respect of a referral of an adult protection matter relating to areas of care practice, which resulted in vulnerability for service users. The inspection visit occurred from 9am to 5pm over eight hours and included talking with service users, a relative, staff and the manager. Some records were inspected; a tour of the building completed and lunch was taken with the service users. There are currently nine service users living at the home. “Have Your Say” comment cards were sent to the home for service users to record their views of the service they receive. Six were completed and returned to the Commission. The inspectors would like to thank the service users/relatives and all who participated with the overall inspection process for their co-operation. The current manager was appointed at the home on 31 October 2005, her application to be registered is currently being processed. Some requirements have been carried forward from previous inspections and additional requirements have been made as a result of this inspection. What the service does well: Information provided by service users and relatives on completed questionnaires and discussions at the home show that they are satisfied with the service provided, in particular the care that staff provide. The service users looked well groomed, comfortable and relaxed throughout the inspection. Service users said that they enjoy the activities, which are arranged on their behalf and said they have enjoyed going out shopping or on trips to the theatre. The meal served at lunchtime was cooked and served to a good standard, service users were assisted appropriately and the interaction in the dining room was good. Service users said they “had some good meals”. The home was clean and tidy and provided a pleasant environment for service users to live in. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Staff training needs must be developed to meet the service users specific needs and abilities. Mandatory training and updates are required; the manager said first aid training was planned for June 2006. Risk assessments had not been completed and the care plans require some further development so that staff are better equipped with the information needed on how to meet identified care needs. There are some concerns in respect of medication, which could affect service users’ health. A referral has been made to the CSCI pharmacist in respect of this to assist the home in making improvements. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 7 The monitoring of service users’ weight is a matter for concern; a requirement remains outstanding from the previous inspection for nutritional assessments to be completed. Some maintenance work is required to ensure the environment is safe and a programme for the replacement of fabric and furnishings should be developed to confirm how items showing signs of wear and tear are to be replaced. Fire training, fire drills need to be completed to ensure service users’ safety. The door opening/locking mechanism on outer door leading onto the side road needs to be repaired or replaced to ensure service users would be able to exit the building if there was a fire. 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.V291223.R01.S.doc Version 5.1 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 Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with contracts, their needs are assessed however service users have yet to receive the service users guide recently developed which should then provide full information for them about the service. EVIDENCE: The manager said the statement of purpose had not been reviewed. The service user guide had been reviewed and Wakefield Metropolitan District Council had been provided with a copy. The Commission has not received a copy as yet. Two-service users’ records seen showed that a contract had been provided and a pre-admission needs assessment had been completed. The manager said new contracts were being developed. Surveys received from five service users stated they had received a contract but another received said that they had not received a contract. The home does not provide intermediate care. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Although there have been improvements made to care planning practices there needs to be much further development of risk assessments and monitoring arrangements to ensure healthcare needs and safety issues are addressed and fully met, although staff attitude is good and courtesy and privacy provided. Arrangements need to be improved for the safekeeping, storage, recording and administration of medication to ensure safe practice. EVIDENCE: The hairdresser was visiting and it was pleasing to see that service users’ hair was cut and styled to a good individualised standard. Service users fingernails were seen to be clean and indicated that personal hygiene has improved. It was pleasing to observe staff on duty speaking to service users respectfully monitoring their dignity and privacy. Service users and a relative spoken with made some very positive comments about the care provided and staff. One Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 11 service user said that “the girls were wonderful and she would not want to live anywhere else”. Four of the six surveys returned from service users informed the Commission that they felt that they always received medical support. The manager had made arrangements for relatives to hold a deceased service user’s funeral tea at the home on a day prior to the inspection, which was a support to all involved. The action to be taken at the time of a service user’s death was seen in their records. The manager said palliative care training had been arranged for eight staff in October 2006. Most service users’ care plans were seen and showed that some progress had been made since the last inspection. An improvement in recording was seen in those completed. Some had been reviewed monthly, however, two had not been reviewed every month. Risk assessments in general were poor and had not been carried out for a service user at risk from falling or in respect of weight loss and pressure area care to ensure their safety. Records of GP, district nurse and other health professionals’ visits had been recorded. There were no nutritional assessments on files seen despite previous requirements resulting from known issues relating to weight loss. An adult protection investigation found that the home had made appropriate referral to Health Care professionals regarding a service user; although this had not been progressed by the health care staff, the home and social care manager were to address this with the Primary Care Trust. The service user’s care plan seen showed that she had not been weighed since admission. The manager said staff were unable to weigh her as the service user was unable to weight bear and therefore was unable to use the “stand on” weighing scales which are used by the home. Some discrepancies were seen on the medication records, which included that on occasions the records had not been signed to confirm that medication had been administered. From examination of the medication administration records it was unclear whether two medications were current or discontinued. Concerns regarding the appropriateness of the medication storage arrangements were discussed with the manager. The manger said 11 staff had received some training from the local pharmacist. The home does not have a shaft lift or medication trolley for transporting medication to service users located over four floors in the home. When staff were asked how medication was transported to service users they said they took the medication in the medication pot individually to the service user. The manager said medication is usually administered when service users are in the dining room. The manager said no service users are prescribed sleeping tablets. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The provision of activities are adequate, service users have the opportunity to go out into the community. Service users’ independence is encouraged and advocacy arrangements are made when needed. Service users are satisfied with the meals. EVIDENCE: An entertainer visited the home in the afternoon of the inspection. Service users said they play bingo occasionally. One of the staff has been appointed as the activities organiser. One of the six completed surveys received felt activities are arranged by the home that they can take part in, four felt there usually are, one felt only sometimes. Two service users said during the inspection that they had really enjoyed a trip to the theatre and that they hoped to go again. One service user said that she had been out on a shopping trip for new clothes with a member of staff. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 13 Some greetings cards made by service users were seen on display in the dining room and a service user’s birthday cards were on display on the mantelpiece in the lounge. Classical music was playing in the lounge; the atmosphere was relaxed and peaceful. A service user’s relative said that he visits regularly and is made welcome. A service user said they would like a telephone in their bedroom this was discussed with the manager who said she would look into this for them. Records seen showed that advocacy arrangements had been made for a service user. The service users were joined in the dining room for lunch, the atmosphere was relaxed and cheerful. The meal was cooked and presented to a good standard, the portions were adequate, and service users spoken with said “the food is good” and that “they get plenty of drinks during the day.” Service users independence throughout the meal was respected and it was seen that assistance was given when needed. As some service users were seen to be struggling to keep food on the dinner plate the use of adapted crockery and cutlery to assist service users to maintain independence and dignity was discussed with the manager. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are able to complain; however outcomes of investigations need to be recorded and responses made to the Commission when requested. The arrangements for service users to vote at general and local elections are satisfactory. Adult Protection training is needed to ensure service users are fully protected. EVIDENCE: Four of the six surveys received from service users stated they know how to make a complaint, two stated sometimes, two always knew who to speak to if not happy, four said they usually knew. It was pleasing to see records confirming that arrangements had been made for a service user to vote by post. The complaints’ record seen did not give clear information in respect of date, time and the outcome of the complaint investigation. The Commission looked into issues around an adult protection referral made to in January 2006. As a result, regulatory requirements were made to the providers for improvements to be made in the provision of care. The Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 15 Commission had not received a response from the registered provider, who has stated after the inspection, that she had thought the requirements referred to a previous adult protection issue that she had responded to by email. A provider raised concerns with the Commission, in relation to a separate issue in respect of a member of staff and an adult protection referral was made. The provider informed the Commission that another member of staff has been dismissed from their employment following allegations of abuse made by a service user against them. The manager had attended an adult protection training course, training records showed that most staff have not had adult protection training. The need for this training was discussed with the manager to ensure that staff have a good understanding of adult protection issues. Staff said that they would report any concerns to the manager. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 16 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): 19,20,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is cleaned to a good standard and provides a pleasant environment for service users to live in. The current arrangements for maintaining the overall environment do not ensure service users’ safety. EVIDENCE: Records seen confirmed that the recommendations made by the fire officer have been completed and good arrangements put into place for training staff on fire safety and for carrying out regular fire drills to ensure service user’s safety. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 17 The homes maintenance programme was not seen on this visit, since the inspection the provider has said this is under review. Throughout the inspection some improvements to the environment were noted. Service user’s bedrooms seen were personalised, clean and generally tidy. The standard of bed linen seen was good and a vacant bedroom was being decorated. Topical creams were seen on top of drawers and hand basins which may pose a risk to service users. The manager was not aware of the home having a development programme for the replacement of fabrics and furnishings and some chairs in the most used lounge were seen to be showing signs of wear. The provider was not present at the visit to discuss this. The lighting in a communal toilet located on the first floor was not bright enough for service users who have diminished eyesight to see clearly. Two pink chairs in a bedroom were seen to be very stained. On examination it could not be established if these chairs and also a large black sofa being stored in the bedroom are fire retardant and discussion took place with the manager about this concern. The sash window in a bedroom was seen to be held open by a box of tissues. The manager said the window cord was broken. The chest of drawers in this bedroom was also seen to be broken. There was no lock on the window located over the hand basin in another bedroom visited. In most bedrooms the chain on the sink plugs on hand basins were broken. Two bed bases seen were stained and a mattress cover torn. Electrical wires leading to a mirror wall light fitting in a service user’s bedroom had not been covered following a repair. It was recommended that the manager contact the electrician that day to arrange for the electrician to return to complete the work required. Before the end of the inspection the manager said she had contacted the electrician who had told her the wires were not live and were safe and he would be calling later in the day to complete the work. A chair lift seat was slightly torn in places and the chair lift seat on the top floor was rough at the back and could cause a risk of injury to service users. In the bathroom on the basement floor the hot water temperature was found to be too running hot at the sink. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 18 Some toilet seats were seen to be showing signs of wear and tear. When leaving the home at the end of inspection it was found that the locking mechanism for the back door leading to the side street was sticking. The manager had great difficulty in opening the door. As this is a designated fire exit discussion took place with the manager about attending to this straight away to allow safe exit in case of fire. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing levels are appropriate given the current number of service users in the home but close monitoring of this needs to be maintained. Recruitment procedures need to improve to ensure service users are protected. Training is needed for staff to ensure service users’ needs are fully met. EVIDENCE: An examination of the staff roster showed that the staffing levels had been reduced from three carers on duty to two on some occasions. The manager said she has covered some care duties to cover sickness and staff vacancies. However, staffing levels were found to be adequate given that there are a number of room vacancies. A discussion was held with the manager in respect of ensuring fire training had been provided for all staff as records seen indicated that there were gaps which the manager had identified and was to address. Discussion also took place about ensuring that a qualified first aider was rostered on duty at all times of the day and night. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 20 A member of staff’s file seen showed that a trainer had discussed equality and diversity with them. An examination of staff files against documents required by regulation showed that for one member of staff recently recruited, a criminal records bureau check had not been completed and the file contained only one reference. However, the member of staff has contacted the Commission to discuss this discrepancy since the inspection. Staff training records showed that training to meet service users abilities, needs, mental health issues and physical disabilities is needed. The manager has arranged for some staff to attend Palliative Care training. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Since the managers appointment in October 2005 she has progressed some of the outstanding breaches in regulation and care practices. There is still much work to be done however and the current support provided by the previous registered manager will need to be structured and ongoing to assist her to achieve this. Whilst records are kept of financial transactions for monies held by the home on behalf of service users, the arrangements for dealing with service user’s finances where the home acts as appointee need to be agreed and clearly recorded. Mandatory training is needed to ensure service users’ safety and welfare is promoted and protected. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 22 EVIDENCE: The current manager has been in post since October 2005. She has NVQ levels 2 & 3 qualifications in care. The Commission is currently processing her application for registration. The manager has made improvements to care planning, the provision of activities and the atmosphere in the home. An enthusiastic, caring and warm attitude towards service users is evident. However, there is much further work to be carried out in relation to some areas affecting service users safety e.g. risk assessments. The manager said that one of the home’s owners visits the home on a regular basis and the Commission is now receiving copies of the report from the Regulation 26 visits as required at previous inspections. Records of staff meetings were seen and showed staff are involved in the decisions and changes in the home. The home’s quality assurance programme was not discussed at this inspection however there was evidence that service users interests are regarded. The manager said she supervises staff on an ongoing daily basis. However, from examining records and from discussion with the manager and staff it was found that formal supervision sessions have not been undertaken. The need to formalise such arrangements was discussed with the manager. Records of service users’ personal allowances were seen. Receipts were seen to be kept for transactions made by the home on service users’ behalf. However, some transactions did not have two signatures. The arrangements for banking one service user’s personal allowance where the provider acts as appointee and arrangements made for paying for outings are not clear from records and care plans. Some staff training records seen showed that mandatory training including fire safety procedures, fire drills, first aid, medication training and also additional training identified necessary to meet service users needs is required. The manager said some first aid training was planned for 1st June 2006. Some equipment and systems checks had been completed. An examination of the hoist certificates showed that two safety belts were inoperative. Discussion took place about ensuring that the hoists could be used safely through risk management processes Running hot water temperature checks at outlets available to service users had been completed and found to be satisfactory. However, no checks had been carried out for the standing water temperatures. On the day of inspection, the Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 23 hot water from the sink in the basement bathroom was too hot to touch and it was recommended to the manager that this needs to be checked for safety. Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 3 18 1 1 2 x 3 3 1 1 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x X 3 X 2 2 X 1 YES Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Castlemount DS0000006172.V291223.R01.S.doc 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 30/06/06 2. OP7 15(1) 13(4) 3. OP8 14 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, 28th October and 31 December 2005 not met Care plans must be generated 30/06/06 from an assessment of risk and service user’s needs reviewed monthly and their relative/ representatives involved. Previous timescale of 25 April 2005 & 28/10/05 not met. The registered person must 30/06/06 ensure that the needs of people living within the home are assessed appropriately and that the assessment is kept under review. Nutritional assessments must be completed for all residents and an appropriate weighing facility provided. Previous timescale of 30 June, 30 November 2005 and 06/02/06 not met The registered person shall make 01/06/06 arrangements for the recording, handling, safe keeping, safe DS0000006172.V291223.R01.S.doc Version 5.1 13(1)(b) 4. OP9 13(2) 14(2)(a) (b) Castlemount Page 26 5. OP16 17(2) Schedule 4 (11) 13(6) Care Standard Act 82(1)(2) (a)(b) 6. OP18 administration and disposal of medicine received into the care home. • A risk assessment must be completed to ensure medication is stored securely and transported safely throughout the home. • The medication records must be signed at the time that the medication is administered to the service user. • The homely remedies must be confirmed with the GP and relocated from the cupboard in the kitchen. • The manager must ensure that the service users’ GP is contacted when the directions regarding service users’ medications are not clear. Timescale 09/05/06 The registered person must ensure that the outcomes of complaints are recorded in the complaint records. The registered person must consider their responsibility in relation to the criteria regarding the referral of staff to the POVA register. Adult Protection training must be provided for all staff. Timescale 31/07/06 The registered person must ensure that door mechanism on the outer door leading onto the side road is repaired or replaced to ensure service users and staff are able to exit the building in the event of a fire occurring. • Fire training must be provided twice a year 09/05/06 09/05/06 7. OP38 OP19 23(4)(a) (c)(iii) 09/05/06 Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 27 8. OP38OP24 16(2)(c) Fire Drills must be held regularly. • The registered person must ensure that all furniture and furnishings provided in the home are fire retardant. • There must always be a member of staff on duty who has been trained in fire safety. The bed bases and mattresses, which are stained, must be replaced. The registered person must ensure that water is stored at temperatures to prevent risks from Legionella. Running hot water temperatures must be maintained to deliver to 43 degrees centigrade to avoid scalding. The registered person must ensure that the provision and maintenance of window restrictors is based on risk assessment and vulnerability of service users. • Window restrictors must be fitted to windows when risks to service users are identified. • 31/07/06 9. OP38OP25 13(3) 30/06/06 10. OP29 19(4)(c) The broken window sash in a service user’s bedroom must be repaired to ensure safety. The registered person must ensure that they are compliant with CRB and POVA guidance and two satisfactory references obtained for all staff before they DS0000006172.V291223.R01.S.doc • 09/05/06 Castlemount Version 5.1 Page 28 11. OP38OP30 18(1) (c)(i) 12. OP35 20(1)(a) (b) commence employment as required by regulation. The registered person must ensure that all staff receive developmental training appropriate to service users needs and that mandatory training is provided. The registered person shall not pay money belonging to a service user into a bank account unless the account is in the name of the service user and the account is not used by the registered person in connection with the carrying on or management of the care home. A record of the care home’s charges to service users including any extra amounts payable for additional service users not covered by those charges, and the amounts paid by or in respect of each service user must be kept. 31/07/06 09/05/06 17(2) 8 schedule 4 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 Refer to Standard OP14 OP15 Good Practice Recommendations The registered person should consider discussing with the service user identified during the inspection their wishes to have a telephone fitted in their bedroom. It would be beneficial for adapted crockery and cutlery to be provided where this need is identified to assist service users during mealtimes and to help maintain their independence and dignity. It is recommended that a programme of routine maintenance and renewal of fabric and decoration of the premises be produced and that when action is taken to DS0000006172.V291223.R01.S.doc Version 5.1 Page 29 3 OP19 Castlemount address identified issues that records kept show the outcome. Consideration should be given to replacing some chairs in the main lounge as they are showing signs of wear and tear. Other issues identified in the body of the report should also be addressed. Areas in the home for use by service users should be appropriately lit including the lighting in the communal toilet. The broken plug chains on the hand basins throughout the home and worn toilet seats should be replaced to prevent cross infection occurring. Two signatures should be obtained on the records for all financial transactions made by the home on behalf of service users. The registered person should ensure that all staff receives supervision six times a year 4 OP20 5 6 7. OP25 OP35 OP36 Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 30 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 © 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 Castlemount DS0000006172.V291223.R01.S.doc Version 5.1 Page 31 - 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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