Inspection on 23/02/06 for Castlethorpe Care Home

This inspection was carried out on 23rd February 2006.

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

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

Other inspections for this house

Castlethorpe Care Home 06/10/09

Castlethorpe Care Home 31/07/07

Castlethorpe Care Home 01/08/06

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

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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 23rd February 2006 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.V284233.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. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 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.V284233.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 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 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.V284233.R01.S.doc Version 5.1 Page 5 Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in February 2006. Records were seen to ensure that staff employed were safe to work with the people who live there and are trained to do their job. Paperwork was also seen to ensure the Company was ensuring the home was safe to live and work in. What the service does well: What has improved since the last inspection? Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 7 The plans kept on the people who live in the home have improved. A new format is being used and this allows the plans to be clearly written, evaluated regularly and sections added if required. This will ensure that everyone’s needs are being addressed at all times. The policy for the use of homely remedies has been revised and the home’s staff, plus the local GP services are now aware of the need to record this accurately and where to consult if the need should arise. This will ensure that all remedies are given safely and no one is put at risk. Staff have now received training in the protection of vulnerable adults and this will ensure that service users are protected from abuse. The Company policy for quality assurance has improved and there was written evidence to support that a robust system is now in place to check that the home and the people working there are safe to work with the people who live in the home. What they could do better: The training records of staff have much improved and all mandatory training appeared to be up to date. Some service specific training had taken place, but there was insufficient evidence to show that this covered all aspects of conditions currently being presented by the people who live in the home. This could put the people at risk from staff not having the most up to date information on each condition. The Company now has a new system for monitoring staff supervision and mentors are being trained in the home. There was insufficient evidence to support that this is being completed on a regular basis, but the means to show written evidence is now available to staff. This will ensure staff can be monitored and action planned if there is a training need to enable them to complete their jobs correctly to safely look after the people who live in the home. Please contact the provider for advice of actions taken in response to this Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 8 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.V284233.R01.S.doc Version 5.1 Page 9 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.V284233.R01.S.doc Version 5.1 Page 10 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): 4 The home needs to provide evidence that staff have been trained to provided for the specific needs of service users. EVIDENCE: The documentation provided by the home, prior to people coming is clear and précis. It gives the prospective service user a good overview of the services provided to enable them to make informed choice. The staff were knowledgeable about the conditions of service users in the home, but there was little written evidence to support that they have received updated training in service specific topics. This will enable them to keep up to date with latest legislation if this is put in place and ensure service users they are using the latest evidence to provide for their needs. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 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): 7,9 and 10. The care plan documentation showed how the service users were being cared for and appeared to be accurately recorded to meet their current needs. Each person was assisted by staff in a caring and dignified manner. EVIDENCE: The care plans had much improved and showed a marked improvement with the new documentation in place. Staff stated that they feel this is easier and quicker to complete, but gives them the opportunity to expand different sections, should the need arise. There was also evidence in the 3 care plans tracked in depth that those funded by the local authority had pre-assessment and key information sheets sent to the home prior to admission. This would assist the staff in preparing for a person’s admission. There was also evidence that the Acting Manager had completed audit tools on the care plan to ensure staff were keeping them up to date. The outstanding requirements that the homely remedies policy be revised was checked and this is now in place. The inspector has also had a telephone Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 12 conversation with the main GP surgery to ascertain their understanding of the home’s role. Staff were observed through out the day assisting service users in a variety of tasks, in a dignified and respectful way. Service users spoken to stated how kind the staff are no matter what their grade or designation in the home. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 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): No standards were inspected in this section on this occasion. EVIDENCE: Castlethorpe Care Home DS0000002777.V284233.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): 18. The home has a robust system in place to ensure service users are protected from abuse. EVIDENCE: All staff have now signed to say they have received informal training in the protection of vulnerable adults. More formal training had been set for later in February 2006 and March 2006. This will ensure they can identify abuse and protect service users in their care. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 15 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. The home was clean and tidy and well maintained and safe for service users to live in. EVIDENCE: The Acting Manager accompanied the inspector on a tour of the main house and The Court. All communal areas were seen, toilets, bathrooms and a selection of service users rooms. All areas were clean and tidy and showed that staff were taking care to ensure that equipment was in place to meet individual service users needs. Some bathrooms have been redecorated and also the dining room in the dementia wing. New chairs had been purchased in the main house, which seemed to meet the current needs of service users. Some corridor carpets had been replaced. The Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 16 Acting Manager is aware that some communal furniture in looking tired and is addressing this with the owner on the new maintenance programme. Individual service users rooms still showed how they can exercise their own independence and how staff are accommodating their needs with the purchase or loan of specialist equipment. The gardens were neat and tidy and free from hazards. The plan of maintenance was seen which details each month action to be taken, by whom and is signed off by a senior staff member when completed. This will ensure that all areas of the home are maintained on a regular basis and can be seen when completed to ensure the service users are living in a comfortable environment. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 17 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): 30 Staff employed have received the basic training to enable them to do their job of looking after service users. EVIDENCE: The Company now has a new policy in place to ensure that staff employed have received a full induction package and have been slotted in to the on going programme of mandatory training. Individual training records were also seen which showed that staff are keeping their training up to date, to enable them to have the latest skills to hand to care for the service users. The records showed the signatories of staff member and also of the trainers. Staff stated to the inspector that they feel this helps to enhance the practical care given to service users. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 18 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. 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. There was insufficient evidence to show that staff have received enough supervision in a year to ensure their individual needs are addressed. EVIDENCE: The Acting Manager is new in post, but not new to the home as she has been the deputy for some years. She is only in charge at Castlethorpe and has two deputies under her and was able to explain, quite ably the rest of the organisational structure. She is currently completing the Registered Manager’s award. The annual development plan for 2006/07 was seen and covered all aspects of the home. Other audits were seen to be in place and the last full audit was Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 19 completed at the beginning of February 2006. Surveys had recently been sent out to service users and their families as part of the consultation process the home has for monitoring the running of the home, some were seen and showed positive comments being made. This ensures that service users needs are being evaluated and that the Company is ensuring the home is maintained and functions at all times for the benefit of the service users. The personal finance records of service users were seen and 5 checked in depth. The records showed accurate recording of transactions and all receipts were present. The balances were healthy and the Administrator spoken to stated that there were no bad debtors at this time. The petty cash and residents fund accounts were also seen and showed good financial control over the systems used. The Acting Manager is currently using a fairly new system for supervision of staff. Everyone is receiving a package of induction, foundation and training records. Each staff member has a job description, which is used as a basis for supervision. Due to the newness of the system and the lack of previous evidence this requirement needs to remain outstanding until more evidence can be produced that the system is working and staff needs are being met. All certificates and other evidence was seen to ensure that the home is maintaining the home well and it is safe to live and work in. Evidence seen included the checks made by the Company’s staff, all certificates in place from outside Companies, accident records and training records. Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Castlethorpe Care Home DS0000002777.V284233.R01.S.doc Version 5.1 Page 21 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. 5. Standard OP4 OP36 Regulation 18.1.c.i. 18.2. Requirement The registered person must ensure that all staff have received service specific training. The registered person must ensure that all staff supervision records can be evidenced. (Previous timescale of 20/04/03 not met and 30/12/05 not met). Timescale for action 30/05/06 30/05/06 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.V284233.R01.S.doc Version 5.1 Page 22 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.V284233.R01.S.doc Version 5.1 Page 23 - 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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