Inspection on 01/08/06 for Castlethorpe Care Home

This inspection was carried out on 1st August 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 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

Castlethorpe Care Home 06/10/09

Castlethorpe Care Home 31/07/07

Castlethorpe Care Home 23/02/06

Castlethorpe Care Home 14/09/05

Castlethorpe Care Home 10/03/05

Castlethorpe Care Home 06/10/04

Castlethorpe Care Home 08/12/03

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Castlethorpe Care Home Castlethorpe Brigg North Lincolnshire DN20 9LG Lead Inspector Theresa Bryson Unannounced Inspection 1st August 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 Castlethorpe Care Home DS0000002777.V307710.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. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castlethorpe Care Home Address Castlethorpe Brigg North Lincolnshire DN20 9LG 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) 01652 654551 01652 651440 Dr Jadwiga Craven Mr Laurence Craven Position Vacant Care Home 77 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (77), of places Physical disability (56), Physical disability over 65 years of age (56), Terminally ill (10) Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Castlethorpe Care Home is a large home providing for the needs of 77 service users. The home is registered for the categories for old age, physical disabilities for over and under 65’s and the terminally ill. The home is divided into 2 parts, the main house and the court, which is a separate building. The court can accommodate service users with minimal needs and specialises in respite care. The main house itself is divided in two sections: a specialist wing for those suffering from the problems of dementia and the rest of the house for those with more acute general care needs and those with chronic and acute nursing needs. The units are staffed separately. The court was built a few years ago and has individual rooms, with ensuite facilities, its own sitting and dining room. There are enough toilets and bathrooms for all service users’ needs. It has a work area for the staff and a small kitchen. There is also a double room facility for relatives who need an over night stay. The garden area is enclosed and all areas have wheel chair access. The main house has a modern extension on a very old farmhouse style house, which retains many of its own features. These rooms also have en-suite facilities, several sitting and dining areas, its own bathrooms and toilets and work areas for the staff. The manager’s office is in this house and there is also a flat on the top floor for staff use. It does have laundry facilities, but the bulk of the linen is sent to the company’s sister home in the same market town. The kitchen provides meals for both houses. Although the home is in a semi-rural setting it is on a bus route to Brigg, approximately 1 mile away and Scunthorpe. It is set in extensive grounds over looking the river and town plus farmland. The home specialises in providing care for a large Polish community, with referrals being made to the home from all over the Country. The home benefits by having a sister home near by for sharing of bank staff and training purposes. The owners make regular visits and have a good deal of input into the home. An efficient head office staff supports it. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 5 The service users guide and statement of purpose are situated in the main reception area of the main house, which is large enough to have a relaxation area where brochures and information on local amenities and events are also placed. Along with the complaints information and suggestion box. Photograph albums are also scattered around showing the home’s history and photographs of all current staff employed. In The Court these items have their own separate copies. The service users guide is always given to prospective service users prior to admission. The residential fees range from £320 to £330 and the nursing fees from £440 to £450. Extra charges are made for hairdressing and chiropody and depend on the treatments given. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 2 days in August 2006 and was unannounced. Prior to the inspection the inspector tracked the previous service history of events in the home. 12 surveys were sent to relatives, out of which 8 were returned. 12 surveys were sent to staff and 5 returned. On the first day of the site visit 3 questionnaires were completed by service users capable of completing unaided. 5 people living in the home were spoken to plus 3 relatives and 9 staff. Records were also seen to ensure safety checks had been made on staff prior to employment and that they were trained to do their job. Records were also seen to ensure the Company were maintaining the building in a safe way for people to live and work in. Provider reports and information sent to CSCI concerning deaths and incidents in the home were also reviewed from the last year. The manager was present for the whole of the inspection and both owners were present for the feed back session. What the service does well: The Company ensures that safety checks are completed on all staff prior to employment and provides training to ensure they can do their jobs. People living in the home made many positive comments concerning how caring and relaxed the staff made them feel. Staff were observed assisting people who live there in a dignified and quiet manner and appeared to be very knowledgeable about each individual. The records provided by the company and processes in place ensure that each person is correctly assessed and all their needs are planned for prior to admission to the home. These are regularly reviewed to ensure all needs are correctly recorded and can be met at all times. People living in home commented on the quality and quantity of the food provided. The menu choices were very varied and took into consideration the many Polish people resident in the home. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 7 Records were seen and during the tour of the home it was seen to be safe and the Company was doing all safety checks to make it a safe and relaxed environment in which to live. What has improved since the last inspection? 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. Castlethorpe Care Home DS0000002777.V307710.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 Castlethorpe Care Home DS0000002777.V307710.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 6. Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The home provides comprehensive information to ensure service users are placed in the correct establishment and have adequately trained staff to meet their needs. EVIDENCE: The statement of purpose and service users since the last inspection. These are given to also on display in both reception areas. It is number of service users and staff employed understand. guide has remained unchanged all prospective service users and is available in Polish for the large and living at the home, to Comprehensive documentation is provided in the home to ensure full holistic assessments are carried out prior to a person’s admission to the home. The assessments are completed by the manager or one of her two deputies. The home insists that those funded by the local authority have information sent on Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 10 them by the local social work team dealing with the person’s care prior to admission. Records were seen which showed when a variety of service users had been assessed and when information had been received. Staff stated that this helps them to prepare for a person’s admission and helps the person to settle in to a new environment. This has proved, the staff stated, very helpful when a lot of there service users have very complex needs to prepare for, before admission. The home has made good progress in evidencing that staff have received not only mandatory training, but also training in specific topics. These topics have included; - palliative care, diabetes, care of the stroke patient and nutrition. The manager needs to ensure that all certificates are included on her training matrix, which helps her keep a track of training completed and required for each staff member. The professionally trained nursing staff keep their own professional portfolios and the manager checks these once a year. The manager ensures that all grades of staff are encouraged to attend training sessions, which ensures they keep up to date and have the latest information to hand when delivering care to service users. The home does not provide intermediate care and therefore NMS 6 is not applicable. Castlethorpe Care Home DS0000002777.V307710.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgment has been made from evidence gathered during and before the visit to this service. The Company provides comprehensive documentation to ensure that all the current needs of service users are delivered and staff are trained and employed to do their job effectively. EVIDENCE: Prior to the site visit 12 relatives survey forms were sent out and 8 returned. 12 staff survey forms were sent out and 5 returned. On the day of the visit 3 service users completed questionnaires and 5 service users were spoken to and 3 relatives, plus 9 members of staff. Many positive comments were made about the attitude and caring manners of the staff and how they felt that all their needs were being attended to. One relative stated that her mother felt she was being “looked after like a Queen”. A service user stated that she “feels safe”, in the home and several made very positive comments about the quality, quantity and choices of food. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 12 6 service users care files were tracked during the course of the visit. These covered a wide range of needs from a respite admission, to self-caring residential service user file, to some who had very complex nursing needs. The staff are using a new format of care documentation. These have been clearly written and offer the opportunity for staff to include special needs of each person. They had been well evaluated and also include an audit trail, which the manager completes. Signatures were seen to be in place to show that the service user them selves, or their next of kin had agreed the package of care offered and that this was reviewed on a regular basis. As the home has a large occupancy of service users from Poland there are staff available at all times to translate and read documentation to those service users and their families, with little or no command of the English language. This has helped them, they stated, to settle in to the home. The files them selves were kept in a very ordered manner and clearly showed the delivery of care to each person. Staff were observed in the main house at lunchtime assisting service users with their meals, which they did in a calm and dignified manner. They were also observed assisting with more personal tasks such as toileting and attending to those with specific nursing needs, in a relaxed and confidant manner. Professionally trained nursing staff spoken to appeared to understand the more complex needs of those service users with nursing needs and could give good account of how certain procedures were performed. In the wing set aside for those with more severe memory loss staff were observed encouraging service users with reminisce therapy and also with a very “jolly” sing-a-long sessions, which every one, in some way or another took part in. In The Court several ladies were knitting together in the main lounge area and were able to describe the sorts of events, to the inspector they most enjoyed, which the home provided for them. Such as entertainments, gardening sessions, quizzes and games afternoons. 2 service users also like the video afternoons were they could watch old movies. The administration of medicines records were checked in both houses and all documentation appeared to have been correctly completed. The deputy manager and senior carer in The Court were able to give a good account of how the ordering and checking system worked. The practises appeared safe and the staff had been trained to perform their role to prevent any risk to the services users who required medication. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 13 Castlethorpe Care Home DS0000002777.V307710.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. 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 provides a variety of activities to ensure that most expectations and preferences of service users are met, except for those with dementia needs. The home provides a nutritionally balanced menu for service users. EVIDENCE: The inspector had the opportunity during the course of the visit to speak to the activities organiser. The records kept by this staff member, showed a variety of events, which had taken place, which were verified by the service users themselves. These included- shopping trips, bingo, board games, bar-b-que and a range of entertainers. Each event was recorded on an individual sheet for each service user and also detailed how they did or did not participate in an event. This is then used to gauge the range of events and following future events. The trained nurses and key workers complete the social needs assessments in the individual care plans. Although those tracked did correspond to the likes and dislikes recorded on the activities organiser sheet, it was recommended Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 15 that some formal way of checking and recording this information is in place, to ensure all details are up to date and meet current needs. Service users and families made many positive comments concerning the activities in the home to the inspector both on the written surveys and verbally. The home appears to ensure that the expectations and preferences of service users satisfies their social, cultural and recreational needs. The home has a large amount of Polish service users and the home ensure there are always Polish staff on duty to help translate. The home also provides books, magazines and current Polish newspapers to help each person to feel at home. Local churches provide regular religious services in the home in both Polish and English. Comments such as, “lovely food and choices” and “tasteful meals” were commented on by service users. The home submitted prior to the inspection the 4-week cycle of menus, which appeared to offer a nutritional balance and also dishes traditional to England and Poland. The head cook accompanied the inspector on a tour of the kitchen and storerooms and was able to give a good account of the running of the kitchen and all records appeared to be in order and correctly completed. Some new crockery and cutlery had just been ordered, but the cook stated there were no restrictions put on the kitchen budget as the owners wished that all nutritional needs were met at all times for each service user. She liaised closely with the professionally trained nurses and they with carers, who predominately assist service users with meals. Each dining area was light and airy and the manager was currently looking at ensuring the main house’s main dining area was also kept attractive and welcoming. Castlethorpe Care Home DS0000002777.V307710.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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 home has a robust system in place to protect service users from abuse. EVIDENCE: No complaints had been received against the service, when the events history was checked prior to the site visit. The policy remains unchanged and was on display at various points around the home. The complaints log was seen and none had been recorded since the last visit. Service users and relatives spoken to stated they had “full” confidence in the management team addressing any issues which may arise and that they would be dealt with promptly and with a sympathetic and caring manner. The manager was able to show the inspector written evidence that staff have undertaken some protection of vulnerable adults training in April 2006. Staff spoken to were able to verify the records and were also able to explain other policies such as whistle blowing and maintaining confidentiality. All policies remain unchanged since the last inspection and staff were able to detail where they were kept. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 17 The Company appeared to have as many safe guards as possible in place to ensure staff are fully aware of how to protect service users from abuse and ensure they live in a safe environment. Castlethorpe Care Home DS0000002777.V307710.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The home was clean and tidy and well maintained and safe for service users to live in. EVIDENCE: The plan of maintenance was on display in the manager’s office. This details all work to be carried out in the forthcoming year and has been completed to show actual work that has taken place and other work which could not take place. This ensures that the manager keeps up to date at all times to ensure the fabric and up keep of the home is well maintained and service users are living in a safe environment. The manager accompanied the inspector on the tour of the main house. Several bathrooms have been identified as needing refurbishing and also the Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 19 carpet in the main conservatory. A new corridor carpet was in place in one corridor since the last inspection. There was ample evidence to show that service users were able to personalize their own rooms, which some stated had helped them, to settle in to the home. All areas were clean and tidy and care had been taken to provide areas where items such as wheelchairs and walking frames and hoists could be stored and help maintain the corridors and rooms as hazard free as possible. In The Court a senior care assistant accompanied the inspector on her tour. There were no problems identified and relatives spoken to stated how much their loved ones liked the en-suite facilities. The standard of cleanliness was high. The gardens at Castlethorpe Care Home remained their spectacular best. Different areas had been provided for walking and also a sensory garden. The home is set in very mature gardens, which are very well maintained by estates staff and all ramped areas were hazard free. Gazebos had been erected in different parts of the garden to allow service users to sit out side the in the hot summer sun. The home appeared well maintained, the environment hazard free and provided a relaxed home to live and work in. Castlethorpe Care Home DS0000002777.V307710.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The home has ensured staff are safe to work with service users prior to employment and are trained to do their jobs. EVIDENCE: All rotas for staff had been submitted prior to the home visit and then checked against current staffing and dependency levels at the site visit. Although the rota appeared to reflect that adequate staff were always on duty and no complaints had been made to the CSCI regarding unmet needs, the manager does not have a regular task, on her audit trail, to ensure this is kept totally up to date. This must be monitored to ensure that adequate staff are always n duty. 6 staff records were tracked in detail and all found to have the necessary documentation in place to ensure they are safe to work with service users prior to commencement of employment. 9 staff were spoken to in depth about their job roles and employment and training in the home. All could give a good account of their roles and appeared to understand the importance of criminal investigation bureau checks, which are in place to ensure they are safe to work with the service users. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 21 The manager has completed a new training plan and also a skills matrix. This identifies where staff have skills, which need to be updated or need to acquire new skills to enable them to work safely with each service user. These are then slotted in to the training plan to ensure training is spread through out the year. Training which had already taken place included mandatory training and some service specific training as detailed at NMS 4. The home currently had just 50 trained to NVQ level 2 or above, which also ensures that they are encourage to develop basic skills around their job roles. Service users can then be assured that they are being looked after by adequately trained staff who can meet their needs. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36 and 38. Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The company has a system in place to ensure that checks are made in the home to ensure it is safe to live and work in. EVIDENCE: A discussion took place with the manager and then with the manager and both owners of the home concerning the management role and their views for the future. Staff and service users stated how they felt that all three persons were kind and had welcomed them into the home. This had made them as one service users stated, “ more loved then at any other time of my life”. The manager’s application was nearing completion and she stated she had grown in confidence over the last couple of years and was developing her own role within the company. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 23 The quality assurance programme has become more developed over the last year. An annual development plan was seen to be in place, with target dates set. It also had review dates against each item and evidence was seen in for example the environment where action had been taken, (such as carpet replacement) and in policy reviews, (such as those for the protection of vulnerable adults). There was also a management general development plan, which also had time scales in place. This has helped the current manager to keep abreast of issues and audit trails in the home to ensure it is safe to live and work in. The manger has kept most records and audits on the computer and has attended a course on computer skills, in which she gained a diploma. This alerts her to audits and events, which need to be tracked. The head office administration team completes finances audits, but written evidence was seen to show these take place on a regular basis. Survey forms were in the process of going out in the next quarter of the year. Service users, relatives and staff also stated that the owners and manager have regular contact with them, which could be seen to be recorded in the notes. The administration team brought evidence of the personal allowance accounts of service users and the residents’ fund. The balances on both were good and the owners appeared to have taken a previous recommendation to ensure that service users’ personal accounts are not allowed to go into a negative balance, which could cause difficulties if the person should leave the home and also showed better accounting management. The supervision records had vastly improved since the last inspection. There was recorded observed supervision as well as discussion. The file had a job description attached, as an aide memoir when supervision takes place. She staff member had a named supervisor, which on discussion with staff they could name. These could be seen to be linked to the training programmes for each individual and staff appeared happy they were taking place and they could see their own progression and monitoring with the company becoming effective. This ensures staff are monitored at all times and are safe to work with this client group. Records were produced to ensure the regular checks had been made and certificates were in place to make the environment safe to live and work in. the manager was aware that as the main building was old she needed to do more regular checks on the water outlet temperatures, which fluctuated at times. The manager had recently developed a system for auditing, on a monthly basis the accident statistics with in the home. This has given her a good opportunity to look at working practise and adapt the home and staff ways of working, if needs have been identified. Evidence was seen in written form that these are passed to staff to see. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 24 The owners of the company have a large input into the home, which service users and staff appeared to appreciate and all Regulation 26 and 37 notices were very full and accurately completed, though out the year. The owners and manager use these, plus telephone and letter formats to keep the CSCI abreast with any developments within the home. Ensuring CSCI is aware it is a safe environment in which service users can live. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18.1.a. Requirement The registered person must ensure that sufficient staff are on duty at all times to meet service users needs ands this is regularly checked by the manager. Timescale for action 20/02/07 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. Refer to Standard OP12 Good Practice Recommendations It is recommended that the key workers liaise with the activities organiser when reviewing the social needs assessments on service users. Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Castlethorpe Care Home DS0000002777.V307710.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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