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Inspection on 18/05/07 for Castletroy Residential Home

Also see our care home review for Castletroy Residential Home for more information

This inspection was carried out on 18th May 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.

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

All staff were observed throughout the inspection to have formed good relationships and a good rapport with service users. The home was able to demonstrate that they treated the residents with dignity and respect. The relative of one resident in their postal survey response commented, "staff are very kind and caring". Keeping relatives informed of any changes and welcoming them into the home with unrestricted visiting times. One resident commented in their survey response, "Castletroy keep my family very well informed on my progress with meetings too". Staff received appropriate regular supervision. The manager had the qualifications and experience to run the home. Residents were consulted and their wishes in the event of terminal illness or death were considered, indicating that the home tackled a sensitive subject to ensure they respected resident`s wishes and preferences.

What has improved since the last inspection?

The system of care plan delivery had improved and the information provided including the details, action and goals had become more consolidated, making them easier for staff to follow and understand. There was a photograph of each resident on their file. Residents falling due to ill fitting footwear had reduced; by including this as part of their falls risk assessment and mobility care planning process. Residents were able to have unrestricted access to their monies when they wished. Needs assessments carried out by the home before admission, were sufficiently detailed to ensure that only residents whose needs they were registered for and could be met were admitted to the home.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Castletroy Residential Home 130 Cromer Way Luton LU2 7GP Lead Inspector Mr Ian Dunthorne Unannounced Inspection 3.15 18th May 2007 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 Castletroy Residential Home DS0000015033.V335110.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. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castletroy Residential Home Address 130 Cromer Way Luton LU2 7GP 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) 01582 417995 01582 723615 No Address for Home Castletroy Home Mrs Jacqueline England Care Home 70 Category(ies) of Old age, not falling within any other category registration, with number (70), Physical disability over 65 years of age (8) of places Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service user must not exceed 70. No one falling within the category of OP may be admitted to the home where there are 70 persons of category OP already accommodated within the home. No one falling within the category of PD(E) may be admitted to the home where there are 8 persons of category PD(E) already accommodated within the home. 25th April 2006 Date of last inspection Brief Description of the Service: Castletroy is a purpose built two-storey home situated on the outskirts of Luton in a residential area. The home is registered to care for up to seventy residents over the age of sixty-five years, eight of whom may also have physical disabilities. Mr Sharma has been the registered provider for several years. Mrs Jacqueline England has worked in the home for a number of years as the deputy and became the registered manager during the last three years. Single room accommodation with ensuite toilet and washbasin facilities is provided for each resident. There are communal areas on both floors such as a lounge and dining room. Shared bathing and toilet facilities are located for convenient access throughout the home. A hairdressing salon and activity room are located on the ground floor. A lift ensures all areas of the home are easily accessible to all residents. There are spacious and well-maintained gardens at the front and rear of the home. Information provided regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in January 2007, both stated that the weekly fee was up to £425.88, exact fees were published in individual service users contracts. Any additional fees not included were also specified and that they would incur an additional charge. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five and a half hours during the afternoon & evening and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from residents, relatives and visitors obtained from postal survey questionnaires. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the person in charge, discussion with residents, their relatives and observation of the routines of the home. The method of inspection was to track the lives of several residents. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and relatives and reviewing their records. What the service does well: What has improved since the last inspection? The system of care plan delivery had improved and the information provided including the details, action and goals had become more consolidated, making Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 6 them easier for staff to follow and understand. There was a photograph of each resident on their file. Residents falling due to ill fitting footwear had reduced; by including this as part of their falls risk assessment and mobility care planning process. Residents were able to have unrestricted access to their monies when they wished. Needs assessments carried out by the home before admission, were sufficiently detailed to ensure that only residents whose needs they were registered for and could be met were admitted to the home. What they could do better: Some of the things that the home could do better include: • Asking for the views of others about what they think of the home and any suggested ideas for improvement. Then producing a plan, showing how they will act upon those views and carry the plan out. Making sure that all residents are consulted and agree to information about how their care should be delivered and provided by staff. Ensuring that medication is properly and safely looked after and that clear, accurate records are kept. Providing suitable activities at weekends, that people who live at the home choose, which they will enjoy and benefit from. Making sure that all residents are offered a suitable choice and variety of food at teatime. Recording investigations of complaints, so it is clear how they reached their decision. Providing training for staff, which would help them understand and meet some of the specialist needs of the residents. • • • • • • 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. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 7 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 Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 8 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, 2, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided sufficient information for prospective residents, however it sometimes failed to produce the information in a suitable format for all residents. This prevented them from being supported to be involved in making a choice about living there. EVIDENCE: Most respondents to the surveys sent to the residents, said that they felt they were given enough information about the home to make informed choices. Residents who were spoken with as part of the inspection supported that evidence. All the relevant information had been included in the information and a copy of the home’s last inspection report was displayed. However the information was not provided in a suitable format for all the intended service users. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 9 Evidence examined confirmed that the residents whose lives were tracked had written contracts with the home, provided with a statement of terms & conditions at the point of moving into the home; this included the fee details. However not all residents or their representatives had signed them to indicate their agreement and consultation and in addition they were not always in a suitable format for the resident. There was evidence that the home had undertaken an assessment of the residents needs on admission and then regularly reviewed this information and updated it when those needs changed; the needs assessment helped them form the basis of their care planning process. They had also been provided with a summary assessment from the referring care management service, which they had used to form part of the information that contributed to their own needs assessment. As a result of a requirement at the home’s last inspection, the home also undertook and had introduced various checks to ensure that only prospective residents, whose needs fell within their categories of registration, were assessed. This improvement helped the home to provide a more robust needs assessment process. The home did not admit service users for intermediate care. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 10 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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for the administration of medication were generally satisfactory. However further development was needed to ensure that records of administration maintained by the home, were always completed and that residents only received their own medication, to safe guard the health and well being of residents. EVIDENCE: A sample of the resident’s care plans were reviewed and found to contain good information to help meet their daily needs and contained concise actions, goals and a photograph identifying the individual resident. Changes to improve the system and presentation had been undertaken and implemented and the benefits of the improvements were clear and were receiving a positive response from staff. There was evidence that the resident or their representative had been involved in compiling the resident’s care plan by consultation and agreement indicated by signing it in some cases but not all, and that they had been reviewed regularly, although at different intervals. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 11 However the resident or their representative had not been involved in the reviews, or consulted about any changes made to the service user plan. The care plan had not been recorded in a style, which was accessible to them. The risk assessments supporting the service user plans had been reviewed regularly. Risk assessments for the prevention of falls were identified clearly for each service user and records of falls were documented accurately. A satisfactory system to identify, manage and reduce the potential risk of individual resident’s falling was in place and staff spoken with provided evidence of a good level of knowledge and understanding to help reduce the risk of falls. The health care needs of the residents were generally met by the home satisfactorily. There was evidence that falls risk assessments had been completed for service users as part of an effective falls management process, which included contacting a healthcare professional after each fall. Some residents pressure areas were being monitored to help the home reduce the risk of them developing pressure sores, which included risk assessments & care plans as part of this process in conjunction with nutritional risk assessments. Staff members spoken with were able to explain why this was and many had received training from the home to support this knowledge. Evidence available supported the fact that residents were enabled by the home to access a variety of health care services, to meet their assessed needs. This was demonstrated by a variety of records and systems followed by the home, including contacting the individual residents’ GP (general practitioner) and maintaining relevant healthcare professional contact records of this dialogue and guidance regarding circumstances under which they should be contacted. Most respondents to the postal surveys said they felt that the home generally met the needs of the resident. No service users were self-medicating at the time of this inspection. Samples of medication records, storage and procedures were checked, of those service users whose lives were being tracked as part of this inspection. All staff administering medication had received training. Further development was found to be required in several of the following areas. There was evidence that common medications were being administered from ‘communal’ boxes, bottles or packets as opposed to the residents’ own individually prescribed medication; in some cases a resident had frequently declined their medication, however there was no evidence to support that the resident’s GP had been advised of this and several gaps were found on the medication administration records (mar’s), where staff should have signed to indicate whether medication had been administered. Each resident’s mar sheet included an accompanying photograph for identification purposes. The evidence from speaking with some residents was that they were treated with respect and their rights to privacy were upheld and this was consistent Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 12 with the relatives and visitors survey responses and observations made during the inspection. Some comments made by residents during the inspection were “The staff absolutely respect my dignity and they are very understanding”; “they listen and not only that they discuss things with you”. The home had a death and dying policy and there was evidence that resident’s wishes in the event of terminal illness or death were recorded. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 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. 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. The home provided satisfactory opportunities for social activities, however this was limited to weekdays only and further development was required to extend the opportunities to include weekends; as a result residents social activity choice can sometimes be restricted. The meals in the home were satisfactory, offering balanced, nutritious and appealing portions. However the choice and variety of food was limited at teatimes and this restricted the choice for the residents. EVIDENCE: No activities provided by the home were observed during this inspection. The home employed two part time staff dedicated to providing and supporting social activities for residents. The home observed resident’s religious needs satisfactorily. Residents who responded to the postal survey and those who were spoken with as part of this inspection, provided a mixed review of the home’s provision of activities for them. It was evident that there were no restrictions placed upon residents regarding, they stated that the daily routines in the home suited them and that there were no rules for getting up or going Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 14 to bed. There was evidence that activities during the weekends when the activities staff did not work were limited and some residents commented on this. Evidence suggested that resident’s were able to maintain regular contact with their relatives and friends without restrictions and were supported to maintain contact if they wished, by the home. Relatives who responded to the postal surveys also supported the evidence and said they felt welcomed by the home when visiting and knew that they could visit at any time. They also said that staff always kept them informed and updated when visiting. There was evidence that residents were encouraged to bring personal possessions with them into the home and consequently in many cases their bedrooms were individualised with their personal possessions. The home was able to demonstrate that they supported resident’s to maintain as much choice and control over their lives as possible in most areas, including financial, as some residents that were able still handled their own financial affairs. Meetings facilitated by the home for the residents were held on a regular basis. Observations were made over the tea time period during this inspection. Resident’s were observed being offered a choice of meals and beverages and those with dietary and religious or cultural needs were accommodated for, including diabetics and vegetarians. Menus examined generally offered choice and a nutritious and wholesome diet to the resident’s, with a balanced and varied selection of foods, although the tea menu each day apart from the dessert appeared the repetitious. The home offered suitable food portions that were well presented. Staff were observed assisting resident’s who required support to enjoy their meals appropriately and sensitively. Residents spoken with said they enjoyed the meals at the home and one said, “if you want something different just ask and they’ll get it, but it’s often too much food!” However some residents who responded to the postal surveys and some who were spoken with during the inspection, said that the tea menus were repetitive and did not offer sufficient choice. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had satisfactory complaints and adult protection procedures in place, which ensured that complaints were listened to and residents were safeguarded from abuse. However further development was required to provide clear evidence and details of any investigations undertook in accordance with the homes complaints procedure, to ensure that the process was conducted appropriately and fairly. EVIDENCE: The home had received one formal complaint and one concern raised which CSCI had been notified formally of since the last inspection. A record was kept of all concerns & complaints. They were investigated and recorded in accordance with their complaints procedure and a record sent to the appropriate authorities if necessary. Records of complaints were examined at the home, amounting to five since the last inspection, however there was limited recorded information provided, detailing how the complaints had been investigated, this was a recommendation at the last inspection. The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. Most respondents to the postal survey questionnaire’s said they knew how to complain and who to speak to if they Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 16 weren’t happy, this evidence was verified by residents who were spoken with during the inspection. The home had satisfactory procedures in place to safeguard residents from abuse. The majority of staff had received POVA (Protection of Vulnerable Adults) training, however several were out of date and a program of refresher training had been planned which was evident. Care staff spoken with knew what to do in the event of witnessing an alleged case of abuse occurring. Since the last inspection there had been one notifiable incident in accordance with the POVA policy and guidance, which was reported to CSCI at the time. Evidence examined, supported a process that had been followed to safeguard and protect residents. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 17 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, 21 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was satisfactory. However there were some identified risks, which need to be addressed, to minimize potential risk to service users and safeguard their health and physical wellbeing. EVIDENCE: This purpose built home had a full time maintenance person at the home, who followed a maintenance program and the home appeared well maintained decoratively. The grounds of the home were tidy, well maintained and allowed access to service users. An environmental health officer had visited the home since the last inspection and the manager said that they had made several requirements. Which as a result action had been taken by the home to comply Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 18 with the requirements and a response in the form of an action plan submitted. The manager also said that the home’s chef had spoken with the visiting environmental health officer since the visit, to ensure their ongoing compliance. The local fire service had also conducted an inspection recently and made some requirements for the home to comply with. The manager said as a result their fire risk assessment had been updated and magnetic door closures were being introduced in phases to the home and that quotes had been obtained in preparation for this work to be undertaken. However evidence of compliance was absent at the time of the inspection. Several toilets & bathrooms were observed to be adequate, however some standard bathrooms were being used for storage purposes only. Staff explained that this was because each bedroom had en-suite facilities and any residents who wished to have a bath, generally used the specialist bathroom facilities, as they were thought to be more adaptable to suit the needs of the residents. Observations made supported this judgement. The home was generally clean and free from offensive odours and the home had a team of support staff including housekeepers and laundry staff to maintain this. Staff training records demonstrated evidence that some staff had received infection control management training and it was also understood that this formed part of staff’s initial induction training. Residents spoken with during the inspection and those who responded to the postal surveys confirmed that that they were satisfied with the comfort and cleanliness of their bedrooms. However some communal toilets and bathrooms within the home, suggested evidence of communal use toiletries and in one case this included razors. This was not an effective infection control system. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 19 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. Staffing levels within the home were satisfactory to meet the needs of the residents. However, the level of specialist training provided for staff to meet the needs of the residents was limited, which could compromise the health and wellbeing of those residents. EVIDENCE: The home provided sufficient numbers of staff to meet the needs of the service users. This evidence was supported by rotas examined, discussions with staff, residents and postal survey respondents. The home had an established group of bank staff to support the home in covering staff holiday, absences and any vacant hours. Training records detailed evidence that 57 of care staff had achieved NVQ level 2 or above. Staff records examined indicated that the homes recruitment procedures were generally satisfactory. Staff that were spoken with supported this evidence. However applicants for employment did not always provide details of their full employment history and there was evidence that the home failed to pursue this before subsequently offering them employment. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 20 Staffs records inspected, showed evidence of individual training but no specific development plans. Staff members spoken with reported various training which they attended, including some recently. However, many staff had not received necessary specialist training to meet the needs of the residents, as the home had not provided it. There was evidence that the home provided staff with the necessary mandatory training, which included an effective rolling program of fire, health & safety, food hygiene, moving & handling and first aid, which was supported by regular refresher training arranged in advance. A training notice board for staff displayed any planned training. The home failed to provide a satisfactory level of specialist training for staff regarding continence, diabetes & sensory impairment necessary to meet the needs of many of the residents. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 21 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, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ views were sought from time to time, but there was limited evidence that their views had much effect in changing how the home was run, & some aspects of the homes health & safety and safe working practice procedures needed further development to ensure residents & staff would be protected from the risk of harm. EVIDENCE: The manager was not present during this inspection, however previous evidence provided and evidence of a displayed certificate examined in the home, demonstrated that the manager was a qualified nurse and has completed her Registered Managers Award (RMA). Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 22 Developing and maintaining an effective quality assurance system within the home, was set as a requirement at the last inspection and had still not been complied with fully. There was evidence that the manager had made some progress since the last inspection but had yet to complete the full quality monitoring cycle, which could then be maintained systematically. One resident spoke enthusiastically of the regularly held resident’s meeting planned for the following week and some issues they intended to raise. The home had recently reviewed and updated many of its internal policies and procedures in January this year, some of which were sampled during the inspection. Copies of these policies were available and openly accessible to staff on each floor. Resident’s financial records and secure safekeeping of money and valuables, were being maintained satisfactorily on behalf of the residents by the home when necessary. The residents financial interests were safeguarded by the home, this protected the interests of the residents. However a witness signature had not been obtained for all financial transactions carried out on behalf of residents, whose money they looked after. Residents spoken with confirmed that they were able to access any monies looked after by the home on their behalf, whenever they wished. Staff spoken to said they were receiving regular supervision. This was supported by recorded evidence on staff files. Staff spoken to said there were regular staff meetings and an advertised staff meeting planned for 29th May 2007 was displayed on the staff notice board. The home’s record keeping was generally satisfactory. However some individual residents daily records were not adequate, as staff had not authenticated the record by signing their full names. Some aspects of the homes health & safety safe working practices, required some improvements to protect residents from potential risk or harm. See ‘Environment’ section of this report. There was some evidence observed within the home’s main kitchen that staff did not wear appropriate personal protective clothing when using chemicals to clean. Health & safety was compromised during the inspection following a bathroom being used by a resident supported by staff, which left a large visible amount of water on the floor, causing a potential slip hazard. However, the door to the bathroom although vacant, had been left open with no visible hazard warning sign or indication of danger due to the wet floor. The home’s water inspection certificate had expired, although this was already being addressed at the time of the inspection. The manager said that an external contractor had been approached to conduct the necessary inspection and compliance checks. Various records were examined to support adequate compliance with safe working practices, regarding health & safety. Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 23 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 2 2 Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Requirement Timescale for action 01/07/07 15 (2) (c) Where possible consultation must be sought from residents about the intended care to be implemented by the home. The care plan should be signed by the resident or their representative on their behalf, to acknowledge the involvement, agreement and consultation with the resident and the care plan should be recorded in a style accessible to the resident. 13 (2) The staff administering the medication must sign for all medications administered to a resident and must only administer medication prescribed and owned by the individual resident and if regularly declined the residents’ GP must be advised of this by the home. 2. OP9 01/07/07 3. OP12 16 (2), (m) & (n) The home must make available 01/08/07 activities that are suitable and varied for residents; to engage in local, social & community activities when they wish to and in accordance with their needs & preferences, including weekends. DS0000015033.V335110.R01.S.doc Version 5.2 Page 25 Castletroy Residential Home 4. OP15 16 (2) (i) Residents must be provided with a suitable choice and variety of food at teatime. The registered person must ensure that any complaint made under the complaints procedure is fully investigated and therefore be able to provide evidence of such an investigation. Staff must receive training appropriate to the work they are to perform, including specialist training to meet the needs of the residents. 01/07/07 5. OP16 22 (3) 01/08/07 6. OP30 18 (1) (c) (i) 18/08/07 7. OP33 12(1)(a)2 4 The registered persons must 01/08/07 ensure that a quality assurance exercise is carried out to seek the views of service users, relatives and other stakeholders. A report of the findings of this exercise must be available for inspection by the CSCI. (Previous timescales of 03/01/06, 31/03/06 and 31/10/06 had not been met in full in that there was no resulting action plan from the exercise) 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 OP1 Good Practice Recommendations The home should ensure that information about the home including service user contracts, the service user’s guide and the complaints procedure, are available in formats DS0000015033.V335110.R01.S.doc Version 5.2 Page 26 Castletroy Residential Home suitable for each resident. 2. OP2 The home should ensure that residents or their representatives sign their individual contract, stating their terms and conditions with the home, to indicate that they have been consulted and agree to those terms. The home should not supply communal toiletries for use in bathrooms / lavatories or leave other residents toiletries in communal bathrooms for general use. The home should ensure that applicants for employment provide details of their full employment history. Where the home handles money for those people living at the home, a witness signature should be obtained for each financial transaction record and the purpose of this clearly explained to the witness. Care staff should ensure that they sign documented care records with their full name on each entry. 3. OP26 4. 5. OP29 OP35 6. OP37 Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Castletroy Residential Home DS0000015033.V335110.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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