Inspection on 08/12/05 for Walshaw Hall

This inspection was carried out on 8th December 2005.

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

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

Other inspections for this house

Walshaw Hall 01/06/06

Walshaw Hall 23/05/05

Walshaw Hall 27/10/04

Walshaw Hall 01/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Capstone Care Limited Walshaw Hall Bradshaw Road Tottington Bury Lancs BL8 3PJ Lead Inspector Mike Murphy Unannounced Inspection 8th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 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. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Capstone Care Limited Address Walshaw Hall Bradshaw Road Tottington Bury Lancs BL8 3PJ 01204 884005 01204 883710 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) Capstone Care Limited Mrs Marilyn Bates Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: Care services at Walshaw Hall are provided in a large adapted property set in its own grounds close to the village of Walshaw that falls within the area of Bury.The property is situated in a pleasant, peaceful semi rural setting with large accessible garden areas.The home provides fifty places for the care of elderly people.There are forty-two single and four shared bedrooms. Thirty-five single and two shared bedrooms have en-suite facilities.This accommodation is provided on three levels with a passenger lift to the first floor and a stair lift to the second floor.Decoration and furnishing is to a high standard. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the home’s second of two annual inspections for the inspection year 2005 to 2006. The first inspection was conducted in May 2005. The inspection took place over four hours. The inspection included discussion with residents, a partial tour of the premises, inspection of care and other records maintained at the home and discussion with staff. The home was being managed well and provided residents with a clean and comfortable environment in which to live. Residents continue to be supported and cared for appropriately and encouraged to make personal choices and retain as much personal independence as possible. What the service does well: What has improved since the last inspection? An ongoing programme of redecoration and refurbishment continues to provide residents with a very comfortable and pleasant environment in which to live. Residents were also very complimentary in respect of the range of activities and events that are planned for them over the forthcoming Christmas period. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 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 Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service Prospective residents are appropriately assessed prior to and after admission to the home. This ensures that their placement is appropriate to meet their needs properly. EVIDENCE: Inspection of care records revealed that all prospective residents undergo a formal pre-admission assessment that is conducted by a senior member of staff from the home. Records of assessment revealed that all the relevant activities of daily life were assessed appropriately and any areas of need in these areas identified. Such an assessment ensures that the home identified precisely what prospective resident’s needs are and that the home will be able to provide the care that individual needs. Such assessments were seen to supplement assessments conducted by other social and health care professionals prior to the admission of a resident to the home. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10. The health and personal care needs of residents at the home were being assessed and addressed appropriately. The arrangements for the management of resident’s medicines were not inspected on this occasion, as they were subject of a separate inspection visit by a CSCI pharmacy inspector. The outcome of the pharmacists inspection was ‘The management of medication has improved but medicines were sometimes ‘shared’ if residents’ own supplies ‘run out’ increasing the risk of administration errors. Staff interacted and assisted residents sensitively and appropriately during the inspection. EVIDENCE: The health care records of 6 residents who live at the home were inspected on this occasion. These were found to contain care plans that were initially based on the pre-admission assessment that is referred to earlier in this report. Care plans addressed the health, personal and social care needs of residents and were evaluated regularly. Risk assessments, that seek to protect resident’s health and safety were also recorded in respect of residents skin integrity, mobility, and nutrition (including weight monitoring) and other relevant areas and were also evaluated regularly. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 10 The evidence obtained at the pharmacy visit was ‘The morning medication round was in progress on arrival at the home. The medication administration records were completed at the time of administration and were generally upto-date. However, two residents had ‘run out’ of one liquid medicine, administration was from bottles originally prescribed for other residents. One of the bottles was not labelled with the name of the medicine; the handwritten label detailed only the residents name and dosage. This serious concern was addressed on the inspection day, new supplies were ordered. The manager advised that the ‘secondary dispensing’ of medicines from pharmacy labelled containers into dosettes for later administration by care staff had been risk assessed and would stop. Written assessment of safe self-administration was available for two residents who administer their own tablets, but was not available for a resident who administered her own eye-drops. The assessments did not include details of the risk management framework for example, details of how the medicines are supplied. The medication storage was generally orderly. There is a dedicated medication refrigerator but the temperature was not recorded to confirm maintenance of the correct temperature. It was observed that eye-drops and other products with a limited in-use shelf-life were not always dated on first opening. Eyedrops prescribed for one resident had been dated, but were in use beyond the reduced in-use shelf-life. This concern was addressed on the inspection day’. Discussion with residents indicated that staff at the home treat them with respect and seek to maintain resident’s dignity and privacy particularly when personal care is being provided. Examples of such comments are ‘ the staff are pleasant and kind’, ‘they care for me well here’, ‘ I can go to the lounge or stay in my room as I choose’, ‘ my family are able to visit at any time’. Residents also indicated in their comments, and this was supported in discussion with staff and inspection of care records, that they are able to access health care services appropriately, this included access to opticians, dentists, and chiropodists. Clearly this assists residents in maximising their health and well being. All residents were registered with a local GP. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The home continues to enable residents to exercise as much personal freedom and choice as possible. The routines of daily living appear to be as flexible as is possible in a residential home setting. Menus were varied, balanced and offered choice. Dining areas within the home were clean, and comfortably furnished. A programme of activities was prominently displayed in the home. EVIDENCE: Discussion with resident’s revealed they were happy with the personal choices and freedom they were able to exercise. They were also very satisfied with the activities provided. Residents were enjoying a programme of exercises designed to maximise their mobility at the time of this inspection. A very varied programme of social activities for the Christmas period was prominently displayed – including details of the home’s annual Christmas Fair. Residents spoke very positively in respect of the food provided at the home, choice of meals and dining areas provided. Comments made included ‘ the food is very good here’, ‘I can choose something else to eat if I don’t like what is on the menu’. Menus were varied, balanced and provided choice. Staff served and assisted residents appropriately and sensitively with their lunch on the day of inspection. This was a hot, substantial and well presented meal. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 12 Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Appropriate measures have been taken to provide an environment where residents and their supporters feel comfortable with making a complaint if necessary, and to prevent residents becoming victims of abuse. These are important areas that are crucial to the protection of resident’s in a care home, many of whom are extremely vulnerable. EVIDENCE: Discussion with resident’s indicated that there was a general awareness and appropriate information provided that enabled people to make a complaint if they desired. Certainly residents and relatives spoken to expressed the view that they felt comfortable enough to raise concerns with the home’s management if they needed to and equally importantly were confident that any issues raised would be dealt with appropriately. Clearly such an approach by the home management means that the vast majority of concerns raised can be dealt with before they escalate into major issues – this can only be of benefit to residents at the home. A detailed and accessible complaints procedure was in place and prominently displayed in the home, which included details of how complainants could contact the CSCI if desired. Inspection of policies and procedures operated at the home and discussion with staff indicated that staff were aware of the importance of protecting resident’s from potential abuse and how to communicate any concerns they Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 14 may have in this area. Staff training has been provided in respect of protection of vulnerable adults. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25,26. The home appeared to be structurally well maintained and continues to provide a comfortable and appropriate environment for residents to receive personal care and accommodation. EVIDENCE: There is decorated and furnished to a very high standard throughout. An ongoing programme of maintenance was in place. All areas of the home designated for resident’s use were accessible to them. Grab rails, ramps, and a passenger lift and other appropriate aids and adaptations are provided to ensure maximum support and encourage independence. Residents spoke very positively in respect of the standard of communal and private (bedroom) accommodation provided at the home A call bell system is provided in each communal and private bedroom for residents and staff to call for assistance. 8 residents bedrooms were inspected on this occasion. These rooms were clean, tastefully decorated, warm, comfortably/appropriately furnished and highly personalised. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 16 Radiators are fitted with guards throughout the home to prevent accidental burning. Radiators can be individually controlled in resident’s bedrooms allowing residents control heating. Current servicing documentation was in place that states that hot water is stored and distributed at the correct temperatures and that thermostatic mixer valves are centrally fitted to regulate the safety of hot water temperatures and regular checks are carried out to monitor this. Laundry facilities within the home are sited away from areas where food is prepared, cooked or eaten. Resident’s laundry is individually marked and is washed and cared for appropriately. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Staffing arrangements at the home appeared to be appropriately managed and suitable to meet the assessed needs of residents at the home. EVIDENCE: Inspection of staffing rotas provided by the home indicated that staffing provision at the home complied with the current minimum requirements that apply to care homes for older people. Discussion with senior carer in charge at the time of this inspection indicated that they were of the view that staffing levels were appropriate to meet the dependency levels of resident’s. Inspection of 2 very recently employed staff personnel files revealed that these contained an application form (including health declaration), and 2 written references. The inspector was however unable to establish whether POVA first checks had been conducted on these two members of staff. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,38 The home was being appropriately managed at the time of this unannounced inspection. This is important as residents need to have confidence in and access to competent managers. EVIDENCE: Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 19 The registered manager was not on duty at the time of this unannounced inspection. However the arrangements to manage the home in her absence were appropriate – with staff being supervised by a senior member of the care staff. The inspector was of the view that the home was well organised and that residents care is well supervised and monitored appropriately. The inspector was given to understand that home is due to undertake its quality audit for this year. The home administers a number of personal allowances of which an income/expenditure sheet with running total is maintained for each resident. 3 accounts were inspected at random and were found to be balanced. Monies are kept separate and are securely stored. Secure facilities are provided for the safe keeping of resident’s monies and valuables. All accidents however minor, that occur in the home were appropriately recorded and written evidence in the homes accident log indicates that they have been appropriately managed. The following safety/servicing certificates were examined and found to be up to date; Yearly gas safety certificate, 5 yearly electrical safety certificate, servicing of passenger lift, servicing of fire safety equipment and the fire alarm system, emergency lighting and nurse call system. An Environmental Health Officer conducted an inspection in January 2005 and made a number of recommendations. The last fire inspection by GM Fire service was dated 29 October 2004 when a number of recommendations were made, all of which have been complied with. However the inspector was unable to establish when the latest staff fire safety training took place. Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X x 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 19 Regulation 16, 23 Requirement That the CSCI are informed in writing what actions have been taken in response to the Environmental Health Officers report dated January 2005 The home must undertake its quality assurance and quality monitoring review for this year. The results should be published and made available to current and prospective residents, their representitives and other intrested parties, including the CSCI. Outsatanding requirement That it I confirmed in writing to the CSCI that a CRB/POVA first check has been conducted on all staff employed at the home as is appropriate That the CSCI are informed in writing the arrangements for staff employed at the home to receive fire safety training That the requirements made in the Pharmacists additional visit report dated the 2nd of December 2005 are complied with. Timescale for action 28/02/06 2 33 24 28/02/06 3 29 19 28/02/06 4 38 23 28/02/06 5 9 13(2) 31/01/06 Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Capstone Care Limited DS0000008410.V270405.R01.S.doc Version 5.0 Page 24 - 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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