Inspection on 27/08/08 for Castletroy Residential Home

This inspection was carried out on 27th August 2008.

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

Castletroy Residential Home 18/05/07

Castletroy Residential Home 25/04/06

Castletroy Residential Home 04/01/06

Castletroy Residential Home 03/10/05

Castletroy Residential Home 15/03/05

Castletroy Residential Home 24/05/04

Castletroy Residential Home 26/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Castletroy Residential Home 130 Cromer Way Luton LU2 7GP Lead Inspector Andrea James Unannounced Inspection 10:30 27 of August 2008 th 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.V358627.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.V358627.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.V358627.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. 18th May 2007 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 four 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. The current fee structure stands at £442.92 per week but additional charges are made for personal belongings. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a 1 star. This means that people who use the service experience an adequate quality outcome. This was an unannounced key inspection undertaken on the 27th of August 2008. The manager was present for the duration of the inspection process which lasted for 8 hours. The report consists of information received from the manager, several relatives, care staff, auxiliary staff, people who use the service and the Annual Quality Assurance Assessment (AQAA) tool received from the home. The report followed a case tracking methodology where a sample of people were selected at random to see what it was like for them living at the home. These people’s care plans were inspected and where possible they, their key staff and relatives were spoken to. The people in this home prefer to be called residents; as a result the word resident will be used to describe the people using this service throughout the report. What the service does well: The service creates a warm and welcoming environment where people are made to feel that they can develop good professional and social relationships. The outcome for residents who live in this home was very good. The service provides 24 hour care to 70 people in an individualistic way that is supported by a dedicated, competent and well skilled staff team. This is enhanced by the input of the external professionals that provides what appears to be a seamless service. Residents spoken to said “it’s a good service, for the money I pay. I get satisfactory care”. Another person spoken to said “I like the home. Its well organised”. One resident said “I am very happy with the home it’s like a hotel”. Relatives spoken to said, “I can’t fault them, the staff always have time to talk and they do a lot of activities for the residents here”. Another relative said “I have nothing but praise for most of the carers”. The home was given a 4 star rating for hygiene when inspected by Environmental Health earlier in the year. The standard of hygiene was visible in the home on the day of the inspection. Relatives spoken to said the meals Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 6 are well presented and people are given choices. On the day of the inspection several relatives were seen consuming different meals. The dietary requirements were met for everyone. There was evidence that forums for listening to people were implemented. People spoken to said they had regular residents meetings and were able to speak to the manager when they needed. Relatives also had annual meetings where they could voice their opinion. What has improved since the last inspection? What they could do better: The home should ensure that: • • • The care implemented for all residents shows evidence that consultation has been sought. A comprehensive assessment tool is implemented that shows a holistic assessment is undertaken for all residents. The overall risk level is identified for risk assessments implemented for residents. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 7 • • • • • The recording of resident’s money shows clear audit trail and witness signatures and receipts are obtained for all transactions so as to safeguard residents from abuse. Effective quality assurance systems are implemented that shows how the home listens to the views of residents and relatives. The home should ensure all doors shut on their rebate in accordance with the fire regulations. The residents should be offered the opportunity to have a key to their bedrooms. All residents should have a call bell in their bedrooms and where this is not achievable; a risk assessment should be in place to show how their needs will be met. 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.V358627.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,3,4,5 &6. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Satisfactory systems were in place to ensure people received enough information about the services the home offers but further development was needed to ensure a comprehensive assessment is undertaken for residents when they are admitted in the home, as a result residents needs could go unmet. EVIDENCE: The home had a Statement of Purpose and a Service User Guide that was implemented in 2006 that covered the aims and objectives of the home, and the complaints procedure. This document is in need of reviewing to reflect the current resources offered in the home. All relatives spoken to said they received sufficient information about the home prior to admission. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 10 Contractual agreements for each resident was available that shows the individual cost of the placement. The contracts seen were signed and dated by residents their represnetatives and the home. The care home gives advance notice of any changes regarding payment. The home has initial pre admission admission assessments which were undertaken for people before they enter the home. They are also offered the oppportunity to have respite care and short stay visits before their placement is made permanent. However there was a need to ensure all residents had a comprehensive assessment of need undertaken once their placement started to ensure all the needs of residents are identified at the onset of the care to be implemented. On the day of the inspection 7 files were inspected and this document was not found, and so it was difficukt to know if all the care need of the residents identified in the care plan was the full picture. Each resident is given the opportunity to visit the home and spend some time within the home before a decision is made. One relative said her mother was in the home for respite care and this allowed her to see if she liked it before the decision would be made. She felt that it gave her mother the opporunity to feel able to make an informed choice. The home did not admit people for intermediate care. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home had safe medication procedures in place and the health care needs of people were identified and implemented in the care plan documentation, however their was no evidence to suggest people were consulted about the care implemented, as a result choice of service delivery could be compromised. EVIDENCE: The home had satisfactory care plan documentation for the 7 residents case tracked. They included the life history, dependency profile, hygiene, falls, incontinence etc. The areas identified were reviewed on a monthly basis and where necessary risk assessments were implemented. Some files showed that an overall review of the care package was undertaken with external professionals but this was not so in all cases. The lack of a comprehensive assessment mentioned previously in the report made it difficult to conclude if all aspects of need for any of the residents were being addressed in the current care plan. Documentation was implemented to ensure the consultation process Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 12 is obtained but this was not adhered to by the staff team responsible for care plans. Relatives and residents spoken to said they were not consulted about the care to be implemented but were happy that the care they received was of a satisfactory standard. One relative commented that he did not like the meals offered to him but once he made his concerns known they were sorted out immediately. The AQAA document stated that residents are supported to make their own decisions and the home uses a person centred approach to care planning. This was not evident in the documents inspected. The risk assessments seen covered risks of falls, manual handling, pressure care and nutrition. These needed further development as some had not been reviewed since March 2006 and the overall level of risk to the resident was not clearly identified. The health care needs were met by the involvement of various GP practices, the district nurses and other external professionals and the communication between the home and the professionals were satisfactorily maintained. The home had satisfactory medication procedures and some residents were encouraged to self medicate. This was clearly identified on the Medication Administration Records (MAR) sheets. We observed staff administering medication to people who use the service and this was done competently. One senior was being inducted into medication on the day of the inspection. The training records suggested all seniors who were allowed to administer medication received satisfactory training and competence checks. The medication storage and recording were satisfactory and staff spoken to appeared competent in the safe administration of medication. Controlled drugs stock inspected suggested safe recording and auditing procedures were in place. The home operates a policy of knocking before entering a residents room wherever possible to ensure privacy, dignity and respect. This was observed to be implemented on the day of the inspection. Castletroy Residential Home DS0000015033.V358627.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. People who use this service experience an excellent quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The lifestyle choices and dietary provisions experienced by the people using this service was exceptional, as a result peoples needs were met. EVIDENCE: The home provided a high standard of activities for people using the service. They had employed two full time activity coordinators and had one volunteer that helps to meet the needs of the residents. The home had an activities room and a record of all residents’ likes and dislikes was recorded. An activity timetable was implemented that incorporated the choices of most of the residents. Interaction was also provided for people who choose not to partake in activities. On the day of the inspection 21 residents were taken to Stock Wood Park and with them several relatives and staff, some staff gave up their day off to facilitate the activity. All relatives spoken to said it was a good day out. There was evidence that people were consulted about what activity they wanted to undertake. One resident said “the activities are very good I like playing boards and skittles”. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 14 Relatives are encouraged to participate in the resident’s lives as much as possible and all relatives spoken to said they can come to the home whenever they liked. They said the staff are always friendly and will stop and talk to them, one relative said “I can’t fault them”. The home has three monthly residents meetings and residents are allowed to make decisions on what they would like to see in the activities programme. The home also had a hair dressing salon but some users are able to have their own hairdressers to come to the home. The family contact for residents in the home is very good. Relatives were in and out the home throughout the day and on the day of the inspection a bus full of relatives who had come to assist with the outing was seen. Several spoken to had positive comments about the care delivered in the home. One relative commented that this was her second experience of using the service and she had no complaints. “She commented that the care was wonderful”. Relatives also have yearly meetings. People are encouraged to make decisions over their own lives. The home was situated in such a way that residents were treated as individuals. One resident said she had booked her hairdressing appointment for that day and later she was seen having her hair done. Some residents had personal telephones in their bedrooms. Some residents choose to have their meals in their bedrooms and this was made possible by the care staff in the home. The meals provided for the residents were of a high standard and catered for various different dietary needs. The head cook spoken to appeared knowledgeable about the needs of all the residents and had achieved all her qualifications to competently care for the needs of the residents. The kitchen staff consisted of 5 people to include the main cook. The home received a 4 star rating for hygiene from the Environmental Health department this year. The meals looked and tasted appetising and choices were offered. On the day of the inspection the cook was also able to meet the needs of the relatives. The meals were presented in a calm and beautiful surrounding and choices were offered for main meal and desserts. Some residents choose to have their meals in their bedrooms and soft diets were presented in an appetising way. All residents had water or a jug of juice in their bedrooms and tea/coffee were offered at regular intervals throughout the day. There was also a communal water fountain for all occupants of the home to partake in. The evening supper was also prepared and appeared appetising with a choice of sandwiches, soups etc. One staff spoken to said she asked residents what they wanted to eat the day before and if they changed their mind on the day their needs would still be met. One relative said “the meals were delicious especially the meats, they are exceptionally tasty”. One resident said, “The food is good here” Castletroy Residential Home DS0000015033.V358627.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. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home had satisfactory systems in place for dealing with complaints and safeguarding them from abuse, as a result residents were protected. EVIDENCE: The home has a clear and accessible concerns/complaints procedure illustrating timescales, and how complaints are dealt with. All residents are informed of the concerns/complaints procedure and are fully supported by staff in making their complaint. The home has incorporated a complaints action record form which tracks how the complaint is investigated and how decisions are reached. Records are kept of all concerns/complaints received and the action which was taken. Since the last inspection three complaints were received. The records seen illustrated that they were dealt with satisfactorily. Relatives spoken to said they knew how to use the complaints procedure should they have the need to. One resident said he recently complained about the way he was being fed especially by new members of staff and the manager resolved the situation satisfactorily. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 16 The home adopts the opinion that all residents have the capacity to make all their decisions unless proved otherwise. Employees are also aware that residents capacity may change daily and this is assessed regularly, for example, residents may have capacity to make a decision about what they want to eat but not about when to eat! All staff are trained in the Safeguarding of Vulnerable Adults (SOVA) and work to these regulations.The home have not had the need to make any safeguarding referrals since the last inspection. Staff spoken to were able to say what they would do in the event that they felt residents were being abused. Staff training records inspected suggested some care staff had received Safeguarding training in the last 12 months. The policy for Safeguarding was not evident in the home. Castletroy Residential Home DS0000015033.V358627.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): People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The environmental standards of the home were satisfactory, but some aspects of the environment needed further development, as a result some people’s comfort could be compromised. EVIDENCE: The home ensures that the environment is well maintained and offers residents a homely place in which to live. People spoken to said “its amazing that a place this big can be so homely”. Another said I can’t believe that the house always smells nice”. On observation the auxillary staff were busy cleaning throughout the day. The home has 1 laundry staff and 4 cleaners along with 1 maintenance person, I window cleaner and 1 gardner. The manager said extra staffing is accessible when rooms need shampooing. The home is maintained appropriately to reduce the risk of infection and cross Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 18 infection. The home provides infection control training to staff so that they are aware of the importance of prevention. Communal space is available within the home for all residents to access and outdoor space is accessible to all residents, including those with mobility problems. Toilet and bathing facilities are available to meet the needs of the residents. Adapted equipment is provided within the home for those residents with limited mobility, for example, grab rails.the experience for one relative was that her mother’s personal hygiene was compromised because the hoist was not charged and therefore could not be used. Some toileting facilities had lights not working and several bin lids were missing from bathroom bins. The disposal of dispoable gloves were seen in several domestic bins. The manager said the staff knew where the gloves were to be placed. One radiator on the upstairs unit was broken and one relative commented that the hoist was not always charged and as a result her mother could not maintain personal hygiene as she would like at all times. The home has a call bell system with an accessible alarm facility in most rooms.ne user did not have a call bell, staff spoken to said the resident kept destroying it. There was no evidence that a risk assessment was implemented to show how the resident could have access to staff when she required. Staff said they carried out half hourly checks. It was also noted that most bedroom doors were proped open and as a result some did not shut on their rebate. The manager said no resident had a key to their bedroom and they were not offered, as they may loose them. All bedrooms seen were furnished to a comfortable standard and had individualised touches.Each room is central heated with controls in each residents room. The home looked and smelled clean throughout with modern decorations and furnishings. There was also a smoking room that is satisfactorily ventilated to meet the needs of people using the service. There was very little evidence that this was a smoking room because it was kept clean with very little smell of cigarette smoke lingering in the vicinity. Castletroy Residential Home DS0000015033.V358627.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. People who use this service experience an adequate quality outcome in this area. We have made this judgment using a range of evidence to include a visit to the service. Staffing levels, and the competency of staff within the within the home was satisfactory, but further development was needed to ensure satisfactory training and development was available for all staff, as a result residents needs could be compromised. EVIDENCE: The staffing levels within the home was satisfactory for the needs of the residents. The rotas showed that on the day of the inspection 5 staff were on duty in the morning and 1 senior while in the evening there was another 5 staff with 1 senior. The night shift has 6 care staff. The manager and administrator are supernumary. The home also had a number of auxillary staff in the kitchen and for general maintenance of the service. The staff team recieves satisfactory training and development to ensure the are competetnt in meeting the needs of the residents. Records sinpsected suggested some staff werer trained in catheter care,stoma care and self harming. Staff spoken to said “ training is very good here”. Notices seen on the notice board showed that training was provided for various courses throughout the year. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 20 Several certificates were seen to suggest mandatory training was undertaken but these were not filed correctly as the pile seen had certificates for staff no longer working at the home. There were no individual training and development plan seen for staff. We were informed that more that 50 of the staff team had achieved their NVQ level 2 or above in care and staff spoken to were able to confirm that they had this qualification but again clear audit trail to triangulate the evidence was not available. The AQAA documentation received suggested that all staff working within the home completed mandatory annual training, applicable to their role within the company, for example, SOVA, manual handling, infection control and fire safety. Staff files inspected suggested that the homes recruitment procedures were generally satisfactory. Staff spoken to supported this evidence.There was evidence that satisfactory references and Criminal Record Bureau checks were undertaken prior to the commencement of employment and staff received an induction when they started. The home had recently implemented a more robust Induction that works in line with the NVQ standard but said they found it difficult to implement due to time restraints. The home ensures that all staff operate in a manner which promotes liberty, that enable residents to feel safe and secure whilst promoting independence. Castletroy Residential Home DS0000015033.V358627.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, 32, 33, 35, 36, & 38. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home has effective management structure in place but the financial interests of people using the service was not safeguarded and effective quality assurance needed further development, as a result people’s best interest was compromised and some residents could be open to financial abuse. EVIDENCE: The management of the home was satisfactory and relatives, care staff and residents spoken to said the manager was approachable and communicated effectively. Two members of staff said “ the manager was fair”. One relative said the manager was very accommodating. Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 22 One relative said the only problem they had was some of the staff team did not speak clearly as english was not their first langauage and so residents may not be able to make their needs understood. One resident commented on this by saying I don’t always understand what some staff say but I don’t let them know as I do not want to offend them. The quality assurance systems within the home was a requirement in the last two inspection reports and have not been complied with. The requirements of this standard was explained in depth to the manager who said she felt able to implement the system. The home have requested questionnaires from relatives and received some feedback but had not analysed them. The home had residents meetings and relatives meeting that was a good source of seeking peoples views but this was not recognised as a form of effective monitoring and so the outcomes of the meetings were not used as a reflective form of quality assurance. The financial policies and procedures within the home needed reviewing to reflect correct procedures for safe receipt, recording and dispensing of residents monies. The home kept monies for some residents which was maintained by the administrator. On inspection of these files we identified that records being used were from 2003 and only one signature was obtained for all transactions. This was also identified in the previous report and a requirement made to the home which was not complied with. The balance for these residents were checked and one was found to be 20 pence short while the other was £4.72 more that the recorded balance. Other transactions showed that as much as £100.00 was received from relatives and residents and dispensed to them without a reciept being obtained. This procedure needs to be adressed as a mature of urgency in order to safeguard residents in the home. Staff spoken to said they received regular supervsion and apparisals and had regular staff meetings. The dates of these were also placed on the notice board. The AQAA documentation stated that induction training and yearly appraisals to identify the learning needs of the staff team was implementd for all staff. The health and safety policies and procedures in the home were met in most aspects however further development was needed to address some shortfalls as identified in the environmental section of the report. Where some doors were propped open and one door failed to shut on the rebate. The fire procedures within the home were satisfactorily maintained and recorded evidence seen suggested weekly and monthly checks were carried out appropriately. Castletroy Residential Home DS0000015033.V358627.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 3 1 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 2 3 4 X x STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 1 3 X 2 Castletroy Residential Home DS0000015033.V358627.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 OP3 Regulation 14 (1) Requirement Timescale for action 31/10/08 2. OP7 All residents admitted to the home must have a comprehensive needs assessment undertaken at the initial stage of the care to be delivered. 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. Previous timescale:01/07/07 30/09/08 3 OP8 4 5 OP22 OP25 All risk assessments must clearly identify the level of risk posed to the resident and must be kept under review. 23 (2) (c ) All equipment used for residents must be in good working order at all times. 23 (4) (a) Arrangements must be made to ensure all doors shut on their rebate in accordance with fire regulations so that residents are protected. DS0000015033.V358627.R01.S.doc 13 (2) (b) 30/10/08 30/09/08 30/10/08 Castletroy Residential Home Version 5.2 Page 25 6 7. OP25 OP30 23 (2) (p) 18 (1) (c) (i) Arrangements must be made to ensure all areas of the home have satisfactory lighting. Arrangements must be made to ensure individual training and development plans are available for all staff showing clearly what training have been undertaken and what needs to be achieved. 30/10/08 30/10/08 8 OP33 12 (1) (a) (2) 9 OP35 10 OP38 11 OP38 Effective quality assurance systems must be in place to seek the views of people using the service. This must be analysed and published. Previous timescales: 03/01/06, 31/03/06, 31/10/06 and 01/08/07. 16 (2) (l) The financial procedures in place must be changed in regards to the safe receipt, dispensing and recording of all transactions, in order to safeguard residents from financial abuse. 23 (2) ( Call bells must be available in all C) residents’ bedrooms and where this is not achievable then risk assessments must be in place to show how residents are safeguarded. 13 (4) (c ) Risk assessments must be in place to ensure the current procedure for disposal of gloves does not put residents at risk. 30/10/08 30/10/08 30/10/08 30/09/08 Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 26 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 Arrangements should be made to ensure that the Statement of Purpose and Service User Guide is reviewed to reflect the current good practices of the home. Arrangements should be made to ensure residents are offered the opportunity to hold a key to their bedrooms. 2 OP25 Castletroy Residential Home DS0000015033.V358627.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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