Inspection on 17/01/07 for Castleton Lodge Care Home

This inspection was carried out on 17th January 2007.

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

Castleton Lodge Care Home 31/07/08

Castleton Lodge Care Home 29/11/07

Castleton Lodge Care Home 07/09/06

Castleton Lodge Care Home 28/02/06

Castleton Lodge Care Home 17/08/05

Castleton Lodge Care Home 15/02/05

Castleton Lodge Care Home 17/08/04

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Snydale Care Home

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

CARE HOMES FOR OLDER PEOPLE Castleton Lodge Care Home Green Lane New Wortley Leeds LS12 1JZ Lead Inspector Valerie Francis Unannounced Inspection 17th January 2007 9: 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 Castleton Lodge Care Home DS0000044491.V320602.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. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castleton Lodge Care Home Address Green Lane New Wortley Leeds LS12 1JZ 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) 0113 231 1755 0113 231 9789 www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Ms Elaine Fitzgerald Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability (2), Terminally ill over 65 years of age (1) Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The place for TI(E) is for the service user specified in the NCSC letter dated 17 December 2003. The places for PD are specifically for named service users Date of last inspection 7th September 2006 Brief Description of the Service: Castleton Lodge Care Home is a detached purpose built property located in Armley, which is on the outskirts of Leeds. The home is owned and managed by Tamaris Health Care Ltd. The property is set in its own grounds with ample car parking facilities available at the front of the premises. There is a bus service along the main road; service users can register with the Access bus, which will drive up to the home. The home is owned and registered to Four Seasons Health Care, as a care home with nursing for up to 60 older people, 30 of whom have Dementia or related mental health problems. The accommodation consists of 60 single rooms, all of which have en suite facilities. There are 8 communal lounges, as well as a large reception area for service users. There are two dining rooms and a central kitchen. There are five communal bathrooms, two showers and eight communal toilets. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was the second key inspection of Castleton Nursing Home. The previous key inspection was undertaken on 7 and 15th September 2006. In addition random inspection visits took place on 27 April 2006. This visit was unannounced and was carried out by two inspectors over one day. It started at 9.00am and finished at 4.30.pm on the 17th January 2007. A peripatetic manager facilitated in the process with the regional manager. Feedback was given to the regional manager. It was noted that some work had started to meet the requirements made at the last inspections. The registered manager has been absent from the home for the last two and half months. The purpose of the visit was to make sure the home was being managed for the benefit and the wellbeing of the residents, and to see what progress had been made in meeting requirements and recommendations made at the last key inspection. Information to support the findings in this report was obtained by looking at the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. CSCI Survey comment cards with post-paid envelopes were sent to the home four weeks before the visit was made to be given to residents and their relatives in order to give people the opportunity to comment on the services provided by the home. Survey cards were also sent to professionals who have contact with the home, however, at the time of writing this report none was returned. Seven residents and three relatives/visitors surveys had been returned to the CSCI. They showed that overall people were satisfied with the standards of Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 6 care provided. One person indicated that they were not entirely satisfied with the standards of care provided; “ I know the home has had many problems and you are trying to put it back to good standards.” They also showed that some people thought there were often not enough staff on duty and not enough activities provided. And they were not aware how to access a copy of the home’s inspection reports. However they said they were made to feel welcome. Records in the home were looked at, such as care plans, staff files, and complaints and accidents records. Residents, their relatives/visitors were spoken to as well as members of staff and the management team. An improvement plan was requested from the registered provider after the last inspection, and as a result some progress has started towards meeting the requirements made and improving the quality of care provided in the home. This has been acknowledged in this report. This progress must continue. Since this inspection the registered provider has sent to the CSCI area office an evaluation\progress improvement plan. A further improvement plan must be sent to the CSCI, giving clear information of the timescales when the requirements that have been made in this report will be completed and by whom. What the service does well: What has improved since the last inspection? At the last inspection 17 requirements and two good practice recommendations were made. An improvement plan was requested to show what system the provider will put in place to resolve the requirements. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 7 This was sent to the CSCI area office noting the changes to the timescale given at the inspection. During this inspection it was noted seven of the requirements made had been resolved or work had started to resolve the matter: • • • • • • • Relatives of residents have been invited to care planning meetings for their relatives living at the home. The provider has increased the staffing level on Moorside during the day to six care staff, and is covered by agency staff until permanent staff are employed. Staff said that they are now involved in handover when residents information is shared before each shift. Staff were seen to be more relaxed when assisting residents with their meals and attending to residents in way that takes in to account their dignity and choice. The home’s records for monies held on behalf of residents had a clear audit trail of all transactions made. Staff now have fire safety training within the guidelines of three monthly for night staff and six monthly for day staff. Estimates have been sought for door locks to residents’ private accommodation. What they could do better: There are four requirements as a result of this inspection. Nine requirements are from the last inspection. This gives a total of thirteen and three recommendations of good practice. The inspector was told that the home’s information document had been reviewed with the requirements made at the last inspections, however a copy was not available for inspection. Training had been given to key staff to make sure that care plans are more person centred and detailed, with residents and their representatives involvement whenever possible. This had not started and care plans seen were still the same. Training for staff on the residents’ illness, such as diabetes, has still not been provided. Each resident must have a plan of care that is personal to their individual needs for staff to follow, and staff must refer to this document rather than rely on verbal information. Without following a plan, important care needs may be missed. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 8 Risk assessments for residents are still not being developed, stating what measures staff must take to reduce and limit the risk. Risk assessments must cover areas such as smoking, the use of hot water bottles, falls, falls from height, low weight, and pressure ulcers. Care plans must be evaluated monthly and a full review of care needs carried out at least annually. The staff administering medication to residents must make sure that they sign for all medication given, and that the record sheet has clear details of all medicine given to residents. Staff must make sure that the policy and procedure for adult protection is followed correctly, and all the required agencies are contacted, when an allegation of abuse is reported. As found at the last inspection the hallway entrance to the building was tidy and comfortable but when entering the home the inspectors found that there was an unpleasant odour. This was also found in the dementia unit Moorside. The provider must give due consideration to replace the floor coverings for these areas to eliminate the unpleasant smell. The registered provider must make sure that the work that has started on the environment on Moorside continues. Some consideration must be given to the replacement of the carpet in the entrance to the home and hallways on Mooside, to eradicate the odour problem in these areas. The provider must make sure that recruitment and selection policy and procedure is followed and the staff involved in the process make sure that application forms have the required details to ensure the form is signed, dated and references received before employment is started. No one to one staff supervision had been carried out, this was to commece on the week begining the 22nd January 2007. The provider must make sure that the two staff designated to provide social activities for and with residents, are provided with training to carry out their work and also provided with a budget to enable them to carry out their role. The matter relating to the social care assessment was still not resolved as no social assessment for new residents was in place. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 9 The registered person must ensure that a minimum of 50 of care workers have achieved NVQ level 2 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. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 10 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 Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 11 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): 1,3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service and discussions with residents and their visitors. Prospective residents did not have access to the home’s up to date information. Service users are assessed before moving in to make sure the home can meet their needs. EVIDENCE: Prospective residents and other interested people have access to information about the home but at the last inspection it was noted that additional information was needed, so that there is clear information about the type of care and who the home offers care to. Although the inspectors were told that Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 12 amendments had been carried out the document was not available for inspection. Residents and their visitors talked about the admission process and the introductory visit, they said they were given information about the home and when they visited they felt welcome. Two people said that they were able to see information about the care their mothers were to receive. Care files for two of the most recent admissions to the home were seen. Preadmission assessments are now routinely carried out to determine that the home can meet the individual needs of the resident. Staff carrying out the assessments have access to a comprehensive document to record care needs however the information seen for two new residents was not enough to put together a full care plan of needs. Two of the visitors spoken to about the admission process could recall, and confirm, that they were involved in the assessment. Intermediate care is not provided in the home. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 13 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): 7,8,9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is still not a care plan in place for all residents. Staff rely on verbal information and prior knowledge when providing care which places residents at risk of not having their needs met. Care plans need further information about the individual, so that they are person centred, to enable staff to know the person, and know how to meet their needs. Residents and their relatives are satisfied with the care provided and with their involvement. EVIDENCE: Four care files were inspected, two from each unit, two of which were residents who had only being living at the home for a short time. The two new residents had little or no written plan of care. Despite the introduction of a new style care plans at the last inspection one of the residents had a plan in place that did do not address all of the areas identified Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 14 in the assessment and instructions for staff were basic. Discussion with staff suggested that they do recognise the importance of following the care plan, however it was evident from the written information seen that they rely on verbal information from colleagues or instructions from individual residents visitors. This approach is dependent on memory and good communication, which can result in some needs being missed. Those residents and visitors seen were aware of the existence or the purpose of the care plan document. There were no risk assessments in care plans for the new residents, others had plans containing some good details to assist the carers in providing the appropriate care package. However, the home must be more aware of the need to reassess an individual when their care needs have changed. One of the residents care files seen did not reflect the changing needs and therefore was inappropriate. Despite this survey, information received from relatives and discussion with relatives at the inspection indicated that they were involved in the care of their relatives living in the home, however, there was no written evidence to indicate this was been carried out. The two new people admitted to the home whose care were case tracked, had no information that nutrition assessments had been carried out. One of the residents on Cleavin despite the assessment indicated that other residents could be at risk from his behaviour. There was no risk assessment with a plan of action to manage/ minimise this potential risk. There was information in some care plans that those residents identified as having a high risk of developing a pressure sores were monitored. There were little or no changes in the care files for those residents with dementia. Written information still shows that the home is attempting to meet the physical needs of the individual, but the primary care need of residents with a diagnosis of dementia is being overlooked. The written information did not look at the resident as an individual, and there was very little information contained within the care files that will assist residents with their dementia needs. A more person centred care approach is needed. The regional manager said key staff who are involved in the care planning process had been sent on training courses, so that all residents have care plans that are person centred and address their personal needs. Overall the care records did not reflect the last wishes of the individual other than saying who would take care of their funeral arrangements. The storage and the administration of medication were inspected. During this time some gaps in the medications administration records were seen, not all staff had been signed for medication dispensed A dispensing system that staff were not familiar with had been brought into the home by a resident who was an emergency admission to the home. Groups of medication had been recorded and although staff said the resident had been Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 15 given the medications there was no written record seen to confirm that the resident had received the medications prescribed. This was brought to the attention of the Regional manager, and the next day following the inspection, the inspector was told that staff was using another administration sheet, which was not seen at the time of the inspection. During the course of the inspection all staff throughout the home were seen to treat residents with respect and attempted to assist them were they could. It was clear from survey information received from relatives that they felt the staff at the home were caring, and they would be contacted if anything untoward occurred with their relative at the home. Good practice was observed during the inspection where resident privacy was given due attention with staff knocking on bedroom doors before entering and ensuring that bathroom and toilet doors were closed when in use. Positive relationships between service users and staff were evident. Residents, relatives spoken to were happy with the care delivered, making comments like “well looked after”, and “it’s super” were made. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 16 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): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff providing activities need more support to carry out social activities. The information displayed for residents was not up-to-date. EVIDENCE: There are three designated staff employed to arrange meaningful activities. Discussions held with staff and comments received from a visitor show that activities, which are age, appropriate, meaningful and interesting to service users are not being provided. Despite staffs’ best efforts, they are finding it very difficult to get an activities programme up and running. Obstacles getting in the way are attributed to lack of specific training and insufficient funds to arrange trips out. Staff say it is difficult to motivate service users to get involved and more staff help is needed with group activities. Staff and relatives meetings have been arranged to discuss how this area of service delivery can be improved. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 17 During this visit service users were observed sitting in the lounges or in their bedrooms, some were reading, others watching television. A group were in a dining room listening to a music tape. Menus examined show a choice of food at every mealtime. Dining room tables were set properly with tablecloths, napkins and appropriate cutlery. Staff were observed offering people choice and providing appropriate support to service users who needed help with their meals. Service users don’t have to eat in the dining room; they can stay in their bedrooms or use other parts of the house. Discussions with the cook showed that every effort is made to provide high calorific food for people who have difficulty maintaining a healthy weight. Service users food preferences are known and medical diets are catered for. Meals that meet the cultural needs of some service users are not provided. Visitors are made welcome and are offered a drink. At the time of this visit there were a number of visitors to the home. Some spoken to confirmed that they can visit at any time and can see their relative in private. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 18 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the required policies and procedures to make sure that residents are protected. Residents and their visitors feel safe and are confident that any concerns they might have will be taken seriously and acted upon. EVIDENCE: An adult protection issue had arisen a week before the inspection, although the home followed it’s adult protection procedure by informing the Local Authority because of the allegation, a key agency was not contacted. This matter has been discussed with the regional manager about the following of the procedure. The person making a notification to the various agencies about an allegation of abuse must give due attention to the type of allegation made and follow their procedure of who to inform. During the inspection both inspectors spoke with various members of staff, many of whom said they knew about the complaint procedure and described it. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 19 The majority of the staff have also received training on POVA (Protection of vulnerable adults.) with plans for others to attend. Survey information from relative and residents indicated that they knew who to complain to and were confident if they had a complaint it would be looked into. Relatives spoken to also confirm that if they had a complaint it would be easy to talk to management without fear of repercussions. In one instance an issue raised with the manager was resolved speedily. The information in the Pre Inspection Questionnaire indicated that since the last inspection there have been two complaints made to the home, all of which had been substantiated and an action plan put in place to make sure the issues do not reoccur. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 20 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): 19 & 20. Quality in this outcome area is adequate, this judgement has been made using available evidence including a visit to this service. The home is pleasant in parts, homely and decorated, maintained and furnished. The odour in the reception entrance to the home and Moorside could create a poor image to visitors. EVIDENCE: A tour of the premises showed the majority of areas to be fresh and clean. The exception to this was the reception area and the dementia care unit, which has an offensive smell of urine. The home employs domestic staff to do the cleaning and laundry staff to do laundry. The accommodation is arranged over two floors and all of the bedrooms are single with ensuite facilities. Service users are encouraged to have some of their personal possessions in their bedrooms, this allows people to have Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 21 familiar things around them and helps promote a sense of individuality and feelings of ownership. There are a number of lounges and dining rooms, which are comfortably furnished. Assisted bathing and shower facilities are available and toilets are strategically placed around the home. Additional aids and adaptations are provided. Decoration to Moorside has started. The regional manager said the home is working with a member of staff in the organisation, with specialist knowledge in dementia care, to provide Moorside with equipments and decorations that will meet the specialist care needs of the residents living in this unit. The Regional manager said there was a plan in place to provide all residents with a specialist bed, which is comfortable to residents and suitable for moving and handling by staff. Memory/orientation boards displayed in dining rooms to assist residents with dementia care needs were showing information relating to the previous day. Such boards should always be showing accurate information if they are to be of any use to people using the service. The home employs a handyman who is responsible for routine maintenance and the monitoring of some health and safety aspects of the premises. At the time of this visit a major refurbishment and redecoration scheme was underway. Decorators were on the premises and a delivery of new furniture arrived. Since the last inspection six bedrooms have been decorated. During the inspection one of the inspectors was approached by a relative who had some concern about the seat which their relatives was sitting on and which they felt was inappropriate. This matter was brought to the attention of the acting manager and an alternative seat was provided. Castleton Lodge Care Home DS0000044491.V320602.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): 27,28, 29 & 30. Quality in this outcome area is adequate, this judgement has been made using available evidence including a visit to this service. The home is not always staffed with staff that know the residents. The permanent staff provide a motivated staff team. The home’s recruitment procedure is not always followed. EVIDENCE: Due to high levels of staff sickness in the last four weeks there has been a high use of agency staff to maintain adequate staffing levels. The inspectors were told that there were 164 hours care staff vacancies in the home, interviews had taken place and two care staff were to start in two weeks following the date of this inspection and two weeks later. All posts are 38.5 hours. Staff were observed providing one to one support to people living in the dementia care unit, enabling them to move around the unit. It was difficult to assess staff training because training records were not up to date. A copy of the organisation’s new induction training booklet and staff handbook was given to the inspectors. This covered the areas of the induction training in relation to the foundation training for Skills for Care. Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 23 The regional manager said plans have been put in place for staff who had not received training for dementia care to undertake the twelve week distance learning courses with a local college. There were plans for further update training for the qualified nurses. There is no recognisable up to date training and development plan for individual staff. One to one formal staff supervision and appraisal is not taking place, Staff spoken to felt that the training and management support is good and enables them to deliver care in a competent manner. A poor recruitment process has the potential to employ unsuitable people and thereby place service users at risk. Staff files examined showed incomplete application forms. Full work histories were not recorded and there was a lack of appropriate references sought. In one case someone had been employed without a criminals record bureau check. Castleton Lodge Care Home DS0000044491.V320602.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): 31,33, 35 & 38. Quality in this outcome area is adequate, this judgement has been made using available evidence including a visit to this service. Residents at the home did not have access to a full and permanent management team. Residents health, safety and wellbeing is protected by the homes policies and procedures EVIDENCE: The Registered manager has been absent from work for some time and both heads of unit posts are vacant. A temporary manager is in post with support from the regional manger. Interviews for heads of units were being held later in the week of this inspection Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 25 At the time of the inspection the management team for the home was the temporary manager supported by the two nurses from the units and the administrator. The regional manager visits the home almost daily to make sure that the home has ample support. The regional manager said that once the heads of units have been appointed, one of which is the deputy manager this will be the full management team for the home. There is a quality assurance and quality monitoring system in place. The regional manager said questionnaires are sent to residents and their relatives. A development plan for the organisation is made from the information collected and analysed with information to be made available to all taking part in the process and any other interested parties. The Regional Manager said a new system of quality audit would be starting for homes in the organisation. The managers from each home will carry out reviews for homes other than their own. There is a good recording system in place for safe handling of resident’s monies in the home with a clear audit trail of all transaction. The administrator is clear about her role in regards to the handling of resident’s money. Good practice was seen where relatives had been sent letters to remind them to keep up with personal allowance for their relative living in the home. Families are encouraged to handle their relative’s affairs. Risk assessments have been carried out for the premises for all potential health and safety hazards. The handy person carries out health and safety checks in the home. It was clear from the records seen that the systems put in place for health, safety checks are adhered to, and good records are kept. Castleton Lodge Care Home DS0000044491.V320602.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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4 Requirement The home’s information must have information on the specialist care provided at the home. And must be readily available to residents and others. Last agreed date 29/05/06 The registered manager must make sure that the person carrying out the assessment collects information that would provide them with a person centred plan of care taking into account the wishes of all the residents. Last agreed dates 31/1/06 & 29/05/06 Timescale for action 05/02/07 2. OP3 14 05/02/07 3. OP7 15 4. OP9 13 (2) 5. OP12 16 2(m & n) A care plan of the action taken to 28/02/07 minimise potential risks must be in place. Last agreed 29/05/06 The registered provider must 28/02/07 make sure that the systems for managing medication are safe. Last agreed timescale 08/11/06 All effort must be made to meet 28/02/07 the social and recreational needs of resident. DS0000044491.V320602.R01.S.doc Version 5.2 Page 28 Castleton Lodge Care Home 6. OP15 12 (3) Designated staff must be given time to provide residents on the specialist unit with meaningful social and recreational activities. Last agreed dates 31/1/06 & 29/05/06 The registered provider must work closely with catering staff to make sure that culturally sensitive meals are offered to residents from a different cultural background. The last agreed 15/05/06 The registered provider must make sure that all agencies are contacted when an allegation of an abuse is made. Some consideration must be given to the replacement of the carpet in the entrance to the home and hallways on Mooside. To eradicate the odour problem to these areas. The registered provider must continue to give staff support in providing Moorside with equipments and decorations that will meet the specialist care needs of the residents living in this unit. Last agreed date 22/05/06 The home must continue with the system in place to have 50 of staff with an NVQ. 30/11/06 Make sure that staff who are being considered for appointment fill in an application form and two references are obtained before employment. The registered person must make sure that staff continue to receive training appropriate to the needs of the residents. DS0000044491.V320602.R01.S.doc 17/02/07 7. OP18 13 05/02/07 8. OP19 23 28/02/07 8. OP19 23 17/03/07 9. OP28 18 17/03/07 10. OP29 18 05/02/07 11. OP30 18 17/03/07 Castleton Lodge Care Home Version 5.2 Page 29 12. OP33 24 13. OP37 17 (2) This must include all areas of health and safety related training, induction and foundation training to Skills for Care standards and specialist training such as dementia. The training needs of qualified nurses must also be addressed. A training plan must be available. 20/12/06 The registered persons must provide the CSCI with a written improvement plan. The improvement plan must set out how they intend to make improvements to the service and the timescale within which this will be achieved. Records required by regulation must be maintained up to date 28/02/07 17/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Detailed records should be kept of all assessments carried out. A due attention should be given to provide residents with accurate information of the day and the food to be served on the day. Some consideration should be given to have a system in place to remind residents what meals are on offer for the day. 2, 3. OP12 OP15 Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Castleton Lodge Care Home DS0000044491.V320602.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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