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Inspection on 31/07/07 for Castlethorpe Care Home

Also see our care home review for Castlethorpe Care Home for more information

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Company provides a comprehensive range of documents to ensure staff can record the actual care delivered to each person. This is checked on a regular basis by senior staff to ensure the current needs of people using the service are being met. These records start prior to admission where an holistic tool records the assessment made on each person, which is then used as a basis to commence a programme of care. Views are sought of each person to ensure the home is being run for their benefit and staff are delivering what they need. Senior staff ensure staff use safe practises at all times through observational supervision, talking to people requiring help and to relatives to ensure everyone`s needs are being met. Attention to detail is observed at all times by staff delivering care to ensure peoples individual expectations are being met. This includes the provision of social and recreational events and provision of a varied diet, which is prepared in a clean and safe environment. Robust systems are in place to ensure that complaints and concerns are dealt with promptly and in confidence, with out comes recorded showing any action which may have needed to have been taken.Regular checks are made to ensure the environment is well maintained and safe to live and work in. personal items are encouraged to be brought in and people living in the home felt their opinions were valued as to the running of the home and decisions made about how they can exercise independence. A robust system is in place to ensure staff are safe to work with the people who live their prior to their commencement of employment and are then trained to do their jobs. A quality assurance system is in place to ensure that the opinions of people who live there, visitors and staff are audited regularly to ensure the Company is running the home for the peoples benefit. Other audits are also in place to ensure that the home is safe and incidents are recorded and action put in place should the need arise.

What has improved since the last inspection?

The home has developed a different system to ensure staffing levels are always adequate enough to meet the needs of service users at all times. This system takes into consideration the training needs of staff and absences due to sickness and holidays. And most importantly the changing dependency needs of each individual. The Company had also chosen to take on board a recommendation made at the last inspection that the activities person liaise more with the key worker for each person living in the home. This has proved beneficial as more individual social, cultural and religious needs have been met, especially with the large number of Polish people resident in the home.

What the care home could do better:

There were no requirements or recommendations set at this inspection.

CARE HOMES FOR OLDER PEOPLE Castlethorpe Care Home Castlethorpe Brigg North Lincolnshire DN20 9LG Lead Inspector Theresa Bryson Unannounced Inspection 31st July 2007 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.V347362.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.V347362.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 cnh.matron@yahoo.co.uk Dr Jadwiga Craven Mr Laurence Craven Mrs Krystyna Jadwiga Thomas 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) Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 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.V347362.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. 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. These fees are reviewed annually and were originally given in 2006. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this key inspection took place over 2 days in July 2007. Prior to this the home had completed the AQAA document, which gives information about the home, sent to them and returned this electronically. 20 surveys were sent out to relatives and people using the service, of which 16 were returned and 20 to staff of which 9 were returned. 7 people resident in the home were spoken to on the site visit day, plus 3 relatives and 10 staff. The inspection record kept by CSCI since the last inspection, for the home was checked plus other records and documents during the site visit. The manager accompanied us throughout the visit and feedback was given to her and both owners on the second day. What the service does well: The Company provides a comprehensive range of documents to ensure staff can record the actual care delivered to each person. This is checked on a regular basis by senior staff to ensure the current needs of people using the service are being met. These records start prior to admission where an holistic tool records the assessment made on each person, which is then used as a basis to commence a programme of care. Views are sought of each person to ensure the home is being run for their benefit and staff are delivering what they need. Senior staff ensure staff use safe practises at all times through observational supervision, talking to people requiring help and to relatives to ensure everyone’s needs are being met. Attention to detail is observed at all times by staff delivering care to ensure peoples individual expectations are being met. This includes the provision of social and recreational events and provision of a varied diet, which is prepared in a clean and safe environment. Robust systems are in place to ensure that complaints and concerns are dealt with promptly and in confidence, with out comes recorded showing any action which may have needed to have been taken. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 7 Regular checks are made to ensure the environment is well maintained and safe to live and work in. personal items are encouraged to be brought in and people living in the home felt their opinions were valued as to the running of the home and decisions made about how they can exercise independence. A robust system is in place to ensure staff are safe to work with the people who live their prior to their commencement of employment and are then trained to do their jobs. A quality assurance system is in place to ensure that the opinions of people who live there, visitors and staff are audited regularly to ensure the Company is running the home for the peoples benefit. Other audits are also in place to ensure that the home is safe and incidents are recorded and action put in place should the need arise. What has improved since the last inspection? What they could do better: There were no requirements or recommendations set at this inspection. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 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.V347362.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are assessed prior to admission using an holistic tool to enable staff to prepare for them and ascertain whether the home can meet their needs. EVIDENCE: During the course of this inspection Standards 3 and 6 were checked. Prior to admission to the home the manager or one of the deputies assesses each person using an holistic tool, which looks at every aspect of a person’s needs. This ensures the home can meet that person’s needs and gives that person and their family opportunity to ask questions and see if they would like to go to stay. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 11 This tool also assists staff in preparing for a person’s admission, which people spoken to stated felt them feel welcomed when first entering the home. The home does not provider intermediate care and therefore Standard 6 is not applicable. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Comprehensive information is kept up dated on each person to enable staff to see what current needs must be met. Safe practises are in place to prevent people from being harmed from unidentified risks and malpractice of drug administration. EVIDENCE: During the course of this inspection Standards 7,8,9 and 10 were checked. Prior to the site visit 22 surveys were sent to relatives and people using the service and 16 were returned. 7 people were spoken to on the day, who were resident in the home and 3 relatives. The home has a high proportion of people who can not make informed decisions and who were extremely ill on the day of the site visit, which meant the service users spoken to were limited. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 13 There has been a continual improvement in the way staff record the actual delivery of care to service users and stated they felt more confident in using the documentation provided by the Company. The follow through to different supplementary evidence was tracked through the 5 care plans seen. There was no difference in the quality of the recording from acutely ill nursing cases to those more able to those suffering from dementia. There was written evidence to support that the managerial team and senior staff check the care plans on a regular basis to ensure staff are recording accurately. This follows the regular evaluation to ensure that current needs of people are being met. Relatives and people living in the home made such comments as “they really look after me” and “mum is always well presented” and “staff keep me informed as mum doesn’t remember”. Comments received in the surveys returned were very positive about the home and stated how well staff respond to requests and the home has a relaxed and friendly feel in spite of its size. Prior to the site visit the inspection record was checked which is kept by CSCI. There was ample evidence to support that notifiable incident forms are sent promptly after events have taken place. The quality of these are of a consistently high standard. Giving very detailed information of events, action taken where necessary and outcomes. Each one is normally faxed as soon as it has been written to ensure the CSCI has the information as soon as it is available. They also showed that where appropriate the home had sought the advice of other health care professionals and other agencies to ensure they were aware of such instances as out breaks of infection, fractures after falls and person’s admitted with poor skin conditions. This has ensured the CSCI is always aware of what is happening in the home and can if necessary help or intervene where appropriate and is aware of serious events and can judge whether the staff have acted appropriately and not in breach of Regulations. One of the 2 deputy managers, who is a professionally trained nurse, escorted the inspector whilst the medication records and storage of medication was being checked. Over the last year there was written evidence to support that the home had provided care for people with very complex needs, having to use a variety of equipment such as feeding pumps and syringe drivers. Staff have been enabled by the Company to keep themselves up to date to ensure they are safe not only to administer medication correctly but also use the variety of equipment in use., as seen in the training files of staff. Through out the 2 days of the site visit we were able to observe staff assisting people in a variety of tasks, such as personal care, exercise classes, meals and Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 14 administration of medication. Each person was talked to calmly and tasks performed with regard to maintaining their dignity. The home has a large number of service users resident who have a Polish background and some staff members are also Polish. The management team try where possible to team Polish speaking staff members with those English speaking staff to ensure, where someone can only speak Polish that their needs can be attended with no fear of not being understood. This was evident when an exercise class was being observed and the instructor was English speaking but there were several staff translating instructions in Polish. Some documentation to aid service users and visitors had been translated into Polish to further ensure there could be no doubt a person could understand processes in place and make informed decision. There was also written evidence that some people attend the Polish club in the local town and visitors come from there to make friends with people living in the home. Those who had transferred from homes and hospital without these facilities stated how comforting it was to speak to others about “the Polish homeland and history”. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of activities are on offer to ensure peoples expectations are being met and the nutritional diet is prepared in a safe and clean environment. EVIDENCE: During the course of this inspection Standards 12,13,14 and 15 were checked. Since the last inspection the Company had taken on board the recommendation that the activities organiser should liaise more with the key workers for each service user. Staff stated this was happening more and to assist this process new record forms had been produced by the management team. Records seen showed that staff were recording not only current needs of people, but also previous life histories, physical and psychological limitations and particular likes and dislikes. Events which have taken place are then recorded on the day and details given as to the person’s level of participation. This is then used as part of the planning process to ensure current needs and expectations are being met. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 16 The records showed that a variety of events had taken place both inside and outside the home and in group and individual sessions. For example mobility and motivation exercise classes are a regular feature in the week, reminiscence sessions take place for those with memory loss, some enjoy being taken out for walks in the local countryside and town. Visitors such as local choirs and ministers of religion attend, with a Mass for Polish people taking place regularly. Reading material was evident in all the sitting room areas with a choice of books, magazines and newspapers in English and Polish. A new feature handed to us was the first newsletter of the home, which is given to each person and visitors and also on display. This had many topical items plus a list of forth coming events. People spoken to felt this was a very “personal feature” and helped their memory not only of events they may have taken part in but also what was coming. One person stated “ it reminded me to send a birthday card to a friend I have made here”. This has ensured that peoples expectations are being met and a variety of events take place to meet individual needs and can sometimes be personalized to them. The head cook escorted us around the kitchen area and storerooms. All areas were very clean and tidy and the last environmental officers report seen by us was very positive about the kitchen environment. Written records were seen to support that regular hygiene checks and cleaning schedules are in place and staff adhering to safety legislation. There appeared to be ample equipment in use and the head cook stated staff had every thing they needed to ensure meals could be prepared well and replacements came very quickly after requests were made. Since the last inspection 3 major items had been purchased – a new large fridge and 2 freezers. Service users spoken to stated that at meal times they felt they could “have what I want” and “I’m never hungry”. Some stated they felt the food was well presented and there was a choice at every mealtime. The 4-week cycle of menus was seen and appeared to be nutritionally balanced. The head cook was also able to explain what types of diet were being catered for, which included diabetics and soft diets for some very ill people. Through out the week there was written evidence to support that special Polish dishes were on the menu (with more traditional English dishes). One English speaking person stated how they liked trying the Polish dishes as they were usually very tasty and “it makes a pleasant change”. The staff ensure that the cultural, social and religious needs of service users are provided for on a regular basis and supporting evidence was seen in the types of activities and meals provided. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Robust systems are in place to ensure complaints are dealt with promptly and service users protected from harmful situations. EVIDENCE: During the course of this inspection Standards 16 and 18 were checked. Prior to the site visit the Company completed the AQAA documentation and sent it to CSCI electronically. This stated there had been no serious complaints since the last inspection. Any concerns that had been raised showed on the documentary evidence had been dealt with promptly, to the satisfaction of all parties. A concern had been raised by a community nursing team last year concerning staff using different methods to give insulin, but the community nursing team put in some additional training and felt satisfied the staff had taken on board their concern and had been cooperative. People spoken to living in the home and relatives stated they had every confidence in the present management team to deal with concerns quickly and in a professional way and confidentiality would be maintained. Staff files also showed that staff had received training in the protection of vulnerable adults and other topics to make them aware of possible abusive Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 18 situations. Such as challenging behaviour and aggression management. Staff stated they felt the training was always appropriate to help them have a sound knowledge base about conditions of people living in the home and enhanced the delivery of care they were able to practise. Policies were checked to ensure they had been reviewed since the last inspection, which the written evidence supported. They were all very detailed and gave clear instructions to staff on how to deal and refer a variety of topics. Other written evidence seen in the care plans tracked showed that staff were evaluating risks to service user and ensuring that alongside the above policies they were being protected from harm. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are able to live in a safe and clean environment free from harm. EVIDENCE: During the course of this inspection Standards 19 and 26 were checked. Since the last inspection a new maintenance and renewal programme has been formulated. This gives details of what is hoped to be achieved monthly and what has actually been completed. This helps the manager to keep on top of outstanding issues and ensures the fabric of the building is being maintained on a time scale to ensure the environment is safe and welcoming at all times. As a temporary measure due to lower occupancy levels The Court facility has been temporarily closed to service users. We checked this and the building appeared safe and secure. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 20 The manager escorted us on a tour of the home where all toilets, bathrooms and communal areas were seen and a selection of people’s rooms. The home was very clean and tidy and written evidence seen that staff are maintaining safety checks in the home and completing their cleaning schedules. There had been some changes of suppliers since the last inspection and some equipment, which needed replacing, but we were assured this was in the hands of the owners, which was later confirmed verbally by them. It was observed that staff take care to ensure there is attention to detail in each room seen. For example ensuring a calendar is in the home language of the person concerned. That special beds and mattresses were in place for the safety of the service user. The dining areas have clean tablecloths and flower arrangements to give a homely touch in which to partake of meals. Survey forms had been sent out and the audit results seen by us for topics such as laundry provision. A pie chart developed and action plan to ensure laundry is provided to the satisfaction of all people. A special snoozelon facility was in part of one of the sitting rooms in the dementia wing to enable service users to feel relaxed. People spoken to stated how it had helped them settle into the home because they were able to bring in their own belongings and make the rooms suitable to their taste and needs. This was evident in the rooms seen. For example assessment made on those who could manage to use a kettle and those who liked lots of ornaments and extra shelving supplied to accommodate them. A new storeroom had been added to one side of the main house which ensures that laundry can now been handled better to prevent cross infection and this has also given more storage space. Part of the first floor has also been further developed for staff use and an office space provided for staff to work on personal course work, with computers provided and Internet access given. Staff stated this has helped them research certain conditions of current service users as well as helped them develop their training needs. The maintenance of the building is of a high standard and written evidence was seen that people living there are asked their opinions of the fabric of the building and how it should develop. The gardens are extensive at the home and offer a variety of settings in which to walk and sit. This includes wooded areas, paved areas, flower gardens and a secure quiet garden for those with memory loss who may wander out of the grounds. Views from the gardens look over the near by town and also open farming countryside, which one person stated helped them keep track of the seasons. There is ample car parking space. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 21 Certificates were seen to show that the management team are ensuring the home is safe and all equipment is in working order. This ensures it is a pleasant and safe place to live and work. The atmosphere being homely and welcoming. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Robust systems are in place to ensure staff are safe to work with service users prior to commencement of employment and are then trained to do their jobs. EVIDENCE: During the course of this inspection Standards 27,28 and 30 were checked. Prior to the site visit 20 surveys were sent out to staff and 9 returned. 10 staff were spoken to on the site visit. Since the last inspection the way the rota system has been put in place has changed to ensure that the managerial team are aware at all times of the dependency of each service user and how many staff are required. The new checking system was seen and also the current dependency level tool in place. Staff stated that there are now adequate staff on duty to address the needs of service users and were aware that some ways of working were beginning to change, such as named drivers for escort and how activities are viewed. Staff commented on the “excellent team work” of every one and how “we all pull together if a crisis occurs”. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 23 Service users also stated that they felt all their needs were being met at all times through a 24-hour period. Commenting on how “smartly dressed” staff always are and “how they allow me to do what I want and can do for myself”. The care staff are supported by domestic, laundry, activities and kitchen staff. Administration work is shared through the head office team and also the gardening and maintenance work, by the team working between this home and a sister home in the same town. This helps to ensure that every ones needs can be met who live at the home and the work is shared through different groups of staff to prevent stressful situations occurring. 6 staff personal files were checked in depth and all found to have the relevant information to ensure safety checks had been made prior to commencement of employment. This included checks made to the Nursing and Midwifery Council for all professionally trained nurses and Home Office papers being place for foreign nationals working at the home. This ensures they are safe to work with people prior to commencement of employment. Training files were all checked and showed how much training had taken place over the last year. This was also detailed in the AQAA returned by the manager. The manager had completed a training matrix on staff so the management team are aware of what traing has taken place and what is required to ensure staff are working to the latest knowledge base on mandatory and service specific training. Individual traing needs are picked up at supervision sessions. Computers and Internet access is supplied by the Company for staff to use and also a quiet area away from service users accommodation. Staff stated this had helped them develop their training needs and stated the training was always thorough and the management team keen to develop a person’s personal development. This ensures staff are trained to do their jobs and can meet service users needs at all times with the latest knowledge base available. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is safe and where their opinions are valued and it is run for their benefit. EVIDENCE: During the course of this inspection Standards 31,33,35 and 38 were checked. Since the last key inspection the manager has passed an interview with CSCI to become the Registered manager of the home. She has also gained her Registered Manager’s Award and maintained her “live” registration with the Nursing and Midwifery Council. All evidence of these topics and the training programme were seen and certificates were on display. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 25 There has been a significant improvement and evidence produced of how the Company quality assurance scheme is working. Since the present management team have been in place the Company has embraced this topic of Regulation. A planner is in place identifying when audits and quality checks need to be completed and pie charts made, for ease of reading when surveys are returned. Topics have included; - meals, laundry and personal care. Action plans were then produced and these needs slotted into whether staff training, maintenance work, operational budget expenditure or areas for discussion with a wider client or staff base were needed. Although some staff stated they felt this type of exercise was time consuming, others felt it was necessary and people using the service stated how they felt their opinions were valued, especially where they could see directly how it was changing and enhancing their own lives. The management staff were looking at new ways to complete audits, such as environment and health and safety issues and how to best encompass the views of health professionals and other visitors to the home. Extensive records were also seen to show that the home is showing due diligence in the way it maintains the safety of the home and any equipment in use and risks identified with service users. These included checks on personal finances of service uses, control of the peoples comfort fund, all equipment certificates and regular checks made of water outlet temperatures and fire safety checks. Service users live in a home, which is well maintained, safe to live in and with a management ethos, which encompasses their views and where their personal risks are regularly assessed. Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 X x 4 Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Castlethorpe Care Home DS0000002777.V347362.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V347362.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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