Inspection on 14/09/05 for Castlethorpe Care Home

This inspection was carried out on 14th September 2005.

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

Other inspections for this house

Castlethorpe Care Home 06/10/09

Castlethorpe Care Home 31/07/07

Castlethorpe Care Home 01/08/06

Castlethorpe Care Home 23/02/06

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 14th September 2005 09:30 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.V250234.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. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 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 Charles William Hammond 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.V250234.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2005 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 proving 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.V250234.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days on September 14th and 15th 2005. To find out how the home was run and if the people who lived in the home were pleased with the care they got, the inspector spoke to the manager, both owners, 11 staff, 8 people who live in the home and 4 relatives. Paperwork kept in the home was also seen to make sure that the checks to makes sure staff are safe to work in the home had been done. And that they had been trained to do their job safely. Paperwork was also looked at to make sure the home and the things it were safe and checked often. One of the owners, Dr.J.Craven accompanied the inspector on the first day and the manager joined her on the second day with the second owner. The delay in this report going out was due to managerial problems in the local office. What the service does well: The home was clean and tidy and had lots of space where people sit and relax or eat. The paperwork provided for people to find out about the home was clearly written and covered all parts of being in the home. It gave lots of information to new people about the home, which would help them make a sound choice. The staff looking after the people who live in the home were friendly and knew a lot about each person. They showed dignity and respect to each person when they approached and assisted them through out the day, in a variety of tasks. The programme of social events each day and planned through out the year were varied and showed that the staff take into consideration the individual needs of the people who live in the home. The variety of food and quantizes for each person were good. The kitchen area was clean and tidy and the menus took into consideration the cultural needs of the people who live in the home, including many Polish people. People of other nationalities may also be catered for at the home. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The paperwork kept on each person who lives in the home could be more up to date and must show current needs. This will enable each person to be cared for correctly and no problems or needs missed. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 7 The home must ensure that staff record all homely remedies given to the people who live in the home and written permission is obtained from their own GP. The trainer for the home must ensure that all staff who work in the home have received training in adult protection, to enable the people to feel safe and to be able to report any adult protection incident correctly. The owners must ensure that all staff have up to date supervision records to ensure they are safe and have the correct information and training to look after the people who live in the home. The owners of the home must ensure that the home is audited and the quality controls are open for inspection, to ensure the staff and home are safe. The manager must ensure that he completes the Registered Manager’s Award to give him the up to date skills to run the home for the safety of all people living and work there. 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.V250234.R01.S.doc Version 5.0 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.V250234.R01.S.doc Version 5.0 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 and 6. Service users are provided with comprehensive documentation before entering the home, to enable them to make informed choice. Staff are given preadmission paperwork to enable them to adequately prepare for a person’s admission. EVIDENCE: The pre-assessment documentation was seen on each service users care plan tracked, as part of the inspection. This remains unchanged from the last inspection. The tool was comprehensive and assessed the service user in a holistic manner. It included a scoring list and dependency guide. The manager or deputy completes all pre-admission documentation and instructions are left for the senior nurses or senior carer, in The Court, to complete on admission. This gives a good basis to prepare staff for any admission and plan a future care plan. More senior staff are supported by the Manager in its sister home, should the need arise. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 10 A new statement of purpose and service users guide has been reviewed by the owners and copies given to the inspector. These included all the items in Schedule 1 of the Regulations. It was comprehensive and would give prospective service users a good overview of the services provided by the home. The home does not provide intermediate care and therefore Standard 6 is not applicable. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 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 11. The home provides comprehensive care documentation to enable all service users needs to be monitored and assist the staff to deliver the appropriate care to each person and administer all medication correctly. The documentation for care plans had not been correctly completed by staff. EVIDENCE: 8 care plans were tracked as part of the inspection process, which were taken from each of the three distinct units of the home. Although the care plan documentation remained unchanged from the last inspection and is a comprehensive tool, staff had not always followed the instructions issued by the company to complete. If completed fully by staff it would give a balanced view of the needs of service users and show the actual delivery of care to each individual. The owner and manager did state during the visit that all care plan documentation was being reviewed and samples of the new format shown to the inspector. This would make completing the documentation and keeping it evaluated easier for staff to follow. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 12 Areas needing to be reviewed on present documentation included: - ensuring service users and their next of kin have seen the care plans and this is recorded, reviews, regular evaluation and monitoring by the manager or appointed person. All staff spoken to were aware that service users can have sight and should be involved in putting the care plan together, but few carried this through on a regular basis. Most of the 8 service users spoken to were not aware, but all 4 relatives spoken to were aware and had been shown their loved ones care plan and felt part of the process of monitoring care. The care plans had improved since the last visit, but staff need to beware that all needs must be recorded so that the correct care can be given at all times to benefit the service users well being. Medication records were checked and the storage of medication had improved from the last inspection. All administration records were checked and recording appeared accurate. Each area of the storage facilities was clean and tidy and the room and drugs fridge temperatures recorded on a regular basis. The senior nursing escorting the inspector appeared knowledgeable about the medication being dispensed to service users and was able to inform the inspector of special needs of some people. The system itself appeared safe, with all polices in place to meet service users needs. During the course of checking some drug administration records it appeared that one local GP was bulk prescribing some medication for the home’s use. The home did not have sufficient evidence to support the rationale behind this decision and was asked to obtain this, in writing from the GP. The home must ensure that all medication, including that being given as homely remedies is accurately recorded, to ensure that errors are not made when administrating medication to service users. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 13 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. The home provided a varied menu to meet service users needs and implemented an effective cleaning programme in the kitchen areas to ensure food was prepared safely for service users. There was a comprehensive activities programme, which involves all service users, encompassing their cultural and religious beliefs. EVIDENCE: The inspector spoke to the activities organiser at length, who has 36 full time hours in the home. The inspector was shown the folder, which contained the assessments of service users, needs and also recorded daily events. This gives a good documentary record of how individuals needs can change and their personal likes and dislikes being addressed. She stated that her involvement with the more chronically ill nursing service users was limited, but evidence in the care plan daily records showed involvement with other staff and on occasions the families and friends of those acutely ill. The written evidence showed a variety of events taking place in the home and with the local community. This included a visit made recently by the Bishop of Lincoln as the home has strong links with the local Anglican Church. It also has links with the Polish church, who give a Mass at the home every Friday. The Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 14 Polish service users are well provided for in the home, with special newspapers in Polish, books, the Polish club visits and service users go to the events outside the home and there are Polish speaking staff, which is useful fore those service users whose only language is Polish. Service users spoken to felt there was a lot going on in the home, which they could take part in and the staff always have an open door policy for attending regular events. The activities listed encompassed all needs of service users and also special events for those suffering from the problems of dementia. Most afternoons the sensory area in one of the sitting rooms in the dementia wing is used for those requiring some quiet time. The home has revised its policy on advocacy, which was seen in the manual by the inspector, since the last inspection. The assistant cook, who was able to give a good account of the running of the kitchen, showed the inspector around the kitchen area. He stated there was enough staff and the rota showed cover from 07:30 hours to 18:30 hours each day of the week. The kitchen was clean and tidy and all store rooms neat and fridges and freezers had been defrosted. There was evidence of good stock rotation and checks made on in coming goods such as fresh fruit and vegetables and meat products. There is always evidence of home baking in the home, which service users stated they enjoyed. The assistant cook was also able to give a good account of the needs of certain service users, for example those requiring a diabetic diet and one person who needs a liquefied diet. The home operates a 4-week cycle of menus, which also include alternative Polish dishes. Some service users stated they enjoyed trying those dishes for a change to normal British dishes. The kitchen appeared to be run well, was clean and gave a varied menu to meet all service users needs. Service users and relatives spoken to gave many positive comments to the inspector on the variety of meals, their presentation and quantity. All dining areas in the home were light and airy and were conducive to service users eating meals in a relaxed atmosphere. Staff were seen to assist service users with dignity and respect. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 15 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. A comprehensive complaints policy was in place for service users and other parties entering the home to see. Service users and their relatives were aware of how to make a complaint, were confident to do so and believed their concerns would be listened to and acted upon. There was a robust policy in place to ensure the service users were protected from abuse, but the training for staff was out of date, which could lead to mistakes being made. EVIDENCE: The complaints procedure remained unchanged since the last inspection and was on display in several areas of the home. The detail was up to date and relatives and staff spoken to were aware of the policy and confident the management team would address any concerns effectively. The policy for the protection of vulnerable adults had been revised and the home had obtained a copy of the local authority guidelines. The manager and all adaptation students had received up to date training, but staff records showed that other staff training was out of date. Failure to train staff could result in serviced users bring placed at risk from abuse. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 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): 19,24 and 26. The home was clean and tidy and the environment safe for all categories of service user. Planning and decoration was evident in the home, making a homely environment for service users to live in. EVIDENCE: The inspector spoke to the housekeeper at length as part of the inspection and the domestic and laundry rotas seen. Staff stated that they feel there are sufficient staff to enable all the tasks to be completed and the inspector was shown the new cleaning schedules and spring-cleaning schedules. This ensures all the areas of the home are covered and spring-cleaning occurs every six weeks. The senior staff completes audits and this ensures a clean safe environment for all service users. The company has purchased new trolleys for the domestic staff, which are neater and easier to keep clean. All COSHH documentation was in place. This has ensured that staff are working in a safe environment. Staff stated that they feel all chemicals are able to cope with all tasks they have to perform. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 17 The maintenance and renewal programme was seen by the inspector and covered all areas of the home. Since the last inspection the company has made many improvements to the home and large areas have been redecorated. Several items of equipment such as beds have been replaced. The major piece of work has been the new lift being installed and this also meant that the landing in that area of the home was redecorated. Service users stated that they feel Castlethorpe is a pleasant environment to live in and staff stated they felt happy with their work surroundings. The grounds and gardens are extensive at the home and there are two areas, which are enclosed for those who may wander. The gardens are colourful all year around and well maintained by a separate gardening staff supplied by the owners. This makes for a very relaxed and pleasant environment for service users to live and many areas have been adapted to suit specific needs. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 18 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. The home has a robust system in place for staff recruitment and training ensuring service users are protected at all times by suitably employed staff. EVIDENCE: The rotas for all departments were seen and staff stated they felt there was adequate staff on duty at all times to meet service users needs. 11 staff were spoken to and each person was clear in their understanding of their job role and the lines of accountability in the home. The home has now reached the target for numbers of NVQ trained staff employed. Staff stated that the course had enhanced their knowledge base for looking after the type of service user living current in the home. 8 staff files were seen and tracked in depth. Each contained the relevant information required under Schedules 2 and 4 of the Regulations. This ensures that suitable staff are employed to protect and care for the service users. The home was employing several Polish staff and Indian adaptation students at the time of the inspection. All records and work permits were in order and documentation seen. The home has a robust system in place and the manager and deputy are assisted by a capable head office staff, who are very familiar with ensuring all documentation is in place and especially for recruiting Foreign Nationals. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 19 All staff had commenced a new training programme in the last month prior to the inspection. The owner has felt that all staff need to refresh their knowledge base with basic skills, which are being tested with the help if a workbook. Evidence was seen on the training records that all statutory and service specific training is taking place. The home also has 3 mentors and 1 University mentor for the adaptation students. They have a training session each Friday as well as working alongside the staff on the clinical floor. Other staff can also attend those sessions, if they wish to up date their skills. There was ample evidence from the adaptation nurses notes to show the topics covered. The home has regular visits by the University to ensure they are meeting the standards required. The training programmes in place in the home ensures they are equipped with all the necessary information and facts for them to deliver care to the service users. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 20 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): 31,32,33,36 and 37. The home does not have a robust system in place to ensure that the quality of care delivered to service users is provided by supervised staff, but has recently reviewed all the policies and procedures to ensure that the information is to hand for staff to access, should needs and problems arise. EVIDENCE: The manager now has enrolled for the Registered Manager’s Award and has kept his training records up to date as he has a “live” professional identification number with the Nursing and Midwifery Council, which he was able to show to the inspector during the visit. Minutes of various staff meetings were seen covering a period of three months. Each meeting appeared well attended by staff and covered a variety of topics. There was also provision for staff to voice their concerns. Staff spoken to state Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 21 they felt they could always voice their views and needs were addressed by the senior management and owners, when needs have arisen. Surveys for service users are now in place since the last inspection and copies were seen which had already been returned. Service users and relatives spoken to stated they felt comfortable in raising issues and these were always dealt with promptly by staff. They also stated that they felt part of any decisions affecting their care and also in the running of the home. The home has recently purchased a new audit tool for the staff to complete, which has yet to be implemented. Doing so will ensure that all areas of the home are audited on a regular basis for the safety of service users and staff. New supervision records have also been recently purchased by the home and mentor/supervisor staff are being given new instructions on how to use the document. This will cover all areas of the home and ensure that staff knowledge base is sound, they have the correct levels of training and are comfortable and happy working in the home and senior management are also not concerned at the level of work provided by them. The home has now reviewed all its policies and procedures after purchasing a new set of documentation. Some of these have been up dated to suit the specific needs of the home and category of service user. The home’s administrator went over these with the inspector and they appeared adequate at this time. Staff are being asked to ensure they are aware of these new policies and sign to say when they have been read. These will enable staff to deliver care correctly to service users and be safe practioners. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 2 3 X Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15.2.b. Requirement The registered person must ensure that all care plans are complete and up to date. (Previous timescale of 29/04/03 not met). The registered person must ensure that all homely remedies are approved by the service users GP and entered correctly on the drug administration records. The registered person must ensure that all staff have received training in the protection of vulnerable adults. The registered person needs to supply details concerning their quality assurance programme plans. (Previous timescale of 20/04/03 not met). The registered person must ensure that all staff supervision records can be evidenced. (Previous timescale of 20/04/03 not met). Timescale for action 30/11/05 2 OP9 13.2. 30/01/06 3 OP18 13.6. 30/01/06 4 OP33 24.1.a, b. 30/01/06 5 OP36 18.2. 30/12/05 Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 24 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 OP31 Good Practice Recommendations The manager is aware that he must commence his Registered Manager’s Award and also the deadline for completion. Castlethorpe Care Home DS0000002777.V250234.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor 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.V250234.R01.S.doc Version 5.0 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!