Care Home: Castle House Nursing Home & Residential Home

What the care home does well There are enough staff on duty, with the necessary mix of skills and experience, to meet people`s needs. This is in part due to senior staff monitoring this well and taking action to provide staffing arrangements that promote people`s wellbeing. Staff commitment and morale is good, with staff feeling well supported. Systems are in place to ensure equipment needed to care for people is safe, through regular maintenance. Arrangements for first aid provision are generally satisfactory. What the care home could do better: There is a plan of care for each person, but in some cases additional information would help to ensure people`s various needs are met and met in a person-centred way. Clarification is needed within the staff team, and between the home and community nursing services, to ensure people`s nursing needs are met appropriately. And aspects of medication management need improvement so that people`s health is promoted and protected. Reviewing arrangements for privacy with regard to some bathrooms or toilets would help to ensure people`s dignity can be respected when using these facilities. Recruitment procedures must be more robust to safeguard people from unsuitable staff. Ensuring all staff carry out appropriate infection control practices would provide the hygiene standards required to give people a clean and pleasant home. Other safe working practices also need to be followed by all staff, so that the health and safety of everyone at the home is promoted and protected. Reviewing certain storage arrangements for equipment would help fire safety measures. Further development of current quality assurance systems - particularly staff supervision, including monitoring of their daily practice, and the registered provider`s unannounced monthly visits - could help the home to identify and address any shortfalls in the quality of its service more effectively. Inspecting for better lives Random inspection report Care homes for older people Name: Address: Castle House Nursing Home & Residential Home Castle Street Torrington Devon EX38 8EZ two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Rachel Fleet Date: 0 2 0 4 2 0 0 9 Information about the care home Name of care home: Address: Castle House Nursing Home & Residential Home Castle Street Torrington Devon EX38 8EZ 01805622233 01805623786 carole.bright@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Cherry Garden Properties Ltd care home 33 Number of places (if applicable): Under 65 Over 65 33 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who can be accommodated is 33. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Castle House is in a quiet residential part of Torrington, close to the countryside yet only 5 minutes walk to the centre of this small rural town. There is ample on site parking space. It was originally a gentlemans residence, which has been adapted for use as a residential and nursing home. Nursing care is provided for up to 33 residents. The rooms are divided over two floors, with the upstairs rooms being accessed by stairs, lift and a stair lift. Currently only one room has en-suite facilities. The home has a large communal sitting room and a separate dining room. The garden to the front of Care Homes for Older People Page 2 of 14 Brief description of the care home the property can be used during the good weather, and accommodates some small domestic animals and birds. The average cost of care at our last Key Inspection was 300-600 pounds per week, depending on whether the individual required 24-hour nursing care. Additional costs, not covered in the fees, include chiropody, hairdressing and personal items such as toiletries and newspapers. Current information about the service, including our previous reports (produced then by CSCI), is available from the home. Care Homes for Older People Page 3 of 14 What we found: We carried out this Random Inspection to check on the homes compliance with certain of the Care Homes Regulations 2001. This was done because of safeguarding concerns raised about care and related records for people living at the home who were known to the community nursing services, as well as concerns about staff recruitment. We were at the home for nine hours before feeding back to the manager, Mrs Bright. We were assisted fully during our visit, readily given information we requested, access to those living at the home as well as the staff, etc. People that we spoke with and observed generally appeared happy. All staff were co-operative and helpful, appearing committed to their work and the home. Of the 25 people living at the home, we were told five were residential rather than nursing status. We case-tracked these people, looking into their care in depth. As such, community nursing services should meet any nursing needs these five people might have, rather than the homes own nurses. Care home staff are responsible for alerting community nurses that such individuals might require their attention. The manager told us that the home was intending to admit only people with nursing needs in future. Because of the nature of the concerns raised, we looked into aspects of the health and welfare of those we case-tracked, including care planning, access to other health professionals, first aid arrangements, recording of injuries, manual handling, use of pressure relieving equipment and manual handling equipment, maintenance of some equipment, safeguarding, and staffing. We found everyone had a care plan addressing a range of needs and risks to peoples wellbeing. However, some lacked detail and holistic, person-centred planning. Daily notes often did not reflect how peoples social needs were met, and did not include goals attained. Written monthly evaluations were often not used for reviewing the effectiveness of care planned or identifying changing needs. For example, where someone who had been losing weight before their admission but who appeared to have lost a lot of weight recently, the monthly evaluation of their care appropriately identified this. But the only change to care then suggested was to weigh the person more often. This was not added to the care plan, the problem had not been raised with a GP or district nurse, and there was no evidence of addressing the persons weight loss otherwise. In another case, there were no plans or risk assessments relating to certain behaviours noted in some peoples care records. Care plans did not include individuals strengths that might be encouraged and supported to enable the person to maintain a level of independence or self worth. Where someone had cancer listed in their medical history, this was not reflected in their care plan under care headings used by the home such as Death and dying. We discussed whether community nurses should be completing the nutritional risk assessment for people of residential status who were identified to have a risk of malnutrition or who were losing weight. The manager was not certain that community nurses had been informed of these peoples weight loss. Care Homes for Older People Page 4 of 14 Care plans stated pressure-relieving equipment was to be used for some people - in response to risk assessments completed by the nursing staff at the home, rather than community nurses. We did not ascertain if community nurses had been involved in provision or the use of this equipment as should be done. Staff and the manager told us no-one had pressure sores or skin wounds currently. One such piece of equipment was at its highest setting, yet the weight of the individual using it indicated the lowest setting should be used. Of two people whose care plans said they should have a pressure-relieving cushion, one had one and the other did not, when we met them. The home ensured people had an annual diabetic check, in line with national health guidelines. We found the homes nurses gave someone their daily insulin; they were unaware of any formal delegation of this nursing task by the community nurses. Related care plans lacked certain details. A recommendation was made about this at our last inspection. Staff were not aware of the expected blood glucose range for the individual, and insulin had been given when their blood glucose was relatively low on one occasion. A nurse confirmed they had not had a recent update on diabetes care. We saw one person had skin lesions, which they said was due to an itching condition. We found nothing about this in the persons care records other than one entry in daily care notes. Senior staff said it was a long-standing problem but the cause was unknown; they were unclear what investigations had been done. Daily care notes for somebody included that they had been seen by a community nurse, with related care advice. However, their care plan had not been updated to reflect this. For another person, there was no evidence that they received treatment for a skin fungal infection, though daily care notes indicated it was reported to community nurses and a treatment cream was to be prescribed. We saw a nurse using appropriate practises when giving out medication. We were told the morning medicine round took 2 hours sometimes - at a time of day when nursing input for personal care might be particularly required or useful. Someones medication dose had been changed by hand on their medication sheet but the change was not signed or dated as is good practise, and nor were handwritten directions for paracetamol. A recommendation was made about this at our last inspection. The latter had a variable dose, but staff had not recorded what they had given, hindering proper assessment of the effectiveness of the medication. We also discussed with the manager that prescribed skin creams had not been dated on opening (so their shelf-life could be monitored), and someone had been given a cough linctus that was not prescribed for them. It was very positive to note that where someone had been prescribed medication to calm them when necessary, they had not been given much of this, suggesting staff themselves were helping the person deal with their agitation. Some toilet and bathroom doors did not have privacy locks. The manager told us this was because some people had locked themselves in and became distressed. We Care Homes for Older People Page 5 of 14 discussed that other ways of ensuring peoples privacy should be looked into. Staff generally had good knowledge of safeguarding matters, describing practises that are considered abusive, such as rough handling and neglect. They said they would report any concerns to senior staff at the home. They were less aware of agencies outside the home that they could contact if necessary, which the manager said she would address with staff. Recruitment practises were not entirely robust, creating a risk that the people at the home might be looked after by unsuitable individuals (see below). We heard a carer asking someone in a wheelchair to tuck their elbows in as they pushed them through a doorway, so that they did not knock the door frame. We did not note any other particular environmental hazards that might cause specific injuries to individuals. Bedrooms and dayrooms were tidy yet homely and personalised. We saw one staff member carrying dirty laundry and a used incopad, without disposable gloves on, along a corridor to a wheelable laundry skip. Such practises increase cross-infection risks to people. Staff felt staffing levels were now sufficient to provide care needed by the current residents, after a period when there had been staff shortages due to sickness and annual leave. A care assistant told us that the home was a happy home, adding If this home was bad, I certainly wouldnt work here myself. Staff morale is good and we all pull together. Some staff told us morning staffing arrangements had just been reorganised, hoping this would prove useful. Files of four staff employed since our last visit had evidence of timely police checks. But two had only one reference (instead of the two written references required), and it appeared the registration number for one nurse had not been verified with their regulatory body until three months after they had commenced employment. The manager was not sure why second references were not available. She agreed to make arrangements that the two individuals would not work a shift whilst a second reference was obtained. Staff confirmed the manager was approachable, and available if they wanted any advice. They felt she knew what was going on in the home. Some but not all staff had had supervision or an appraisal in the last year by the manager. One staff member said staff monitor each other, and Senior carers also had a particular role in monitoring practise. We looked at the providers reports that are required by us. Those we saw were minimal in detail, and had been completed every three months, rather than monthly as we require. Record of events had been interpreted as social activities rather than untoward occurrences, etc. It was not clear that the quality of nursing care was assessed on these visits. During our visit, it was very positive to see staff working in pairs to assist people, taking time and explaining to individuals what they were about to do. Bedrooms of those who needed hoisting were big enough to make use of such equipment safely Care Homes for Older People Page 6 of 14 possible. However, we saw staff use a lifting sling that was too large for the individual, causing the person distress as their arms were pulled abnormally. Some staff said they used whichever sling was available if the small sling was in the wash. Senior staff observed the transfer but did not intervene to correct staff. All wheelchairs we saw had footplates. These were not always used, so some peoples feet were unsupported as their feet did not reach the floor. This can be come very uncomfortable. One person who had recently had an unexplained skin tear on their arm cried out that the wheelchair armrest was cutting her arm; we saw their arm was in the gap in the side of the wheelchair. Staff said they had had manual handling training, which had included use of hoists and slings but not working with specific individuals at the home or the use of wheelchairs. Staff told us there were two hoists. The manager explained that staff preferred to use two particular hoists, which converted to standing aids, although others were available. We saw evidence that five hoists had been serviced six-monthly, including inspection of slings, the most recent being January 2009. This was reflected on Health and Safety Inspection Checklists completed monthly in 2009 by the manager. The manager said all nurses usually had first aid training so that there was always a first aider on duty, and a new nurse we spoke with would be attending the next course booked. We were told that since safeguarding concerns relating to unexplained skin tears were raised with the home, a new procedure was in place, with Incident forms completed for skin flaps or bruises of unknown cause. Care assistants could complete these, as we saw reflected in daily care notes. Our conversations with staff suggested there was lack of clarity about the use of Accident forms, however. The manager had a system for auditing accidents, particularly looking at staff numbers on duty and time of day. We discussed with her expanding the range of occurrences considered accidents, and the factors audited, for fuller monitoring of accidents. We also discussed the distinction being made between accidents and incidents, in view of staff confusion. We saw wheelchairs stored on one occasion in a way that hindered access to a fire extinguisher. The manager told us this had been discussed last year with the fire authority, nothing was stored there at night so the extinguisher was accessible then, and a more suitable location could not be found for it or the wheelchairs. We have contacted the local fire authority for further guidance, and advise the home do so again. The home had begun to address issues recently brought to their attention, with a willingness expressed to do more as necessary. However, a number of requirements and recommendations have been made following this inspection. Because of our findings, we will now carry out a Key Inspection this year to inspect all core National Minimum Standards, including any action taken to address the requirements and recommendations. Care Homes for Older People Page 7 of 14 What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 8 of 14 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 9 of 14 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 You must have, for each 11/07/2009 person living at the home, a care plan detailing how their health and welfare needs are to be met, and revise the plan as necessary, in consultation with the individual where possible To ensure peoples individual and diverse needs are met, in a person-centred way. 2 8 13 You must make appropriate 11/06/2009 arrangements for people living at the home to receive, where necessary, treatment, advice and other services from community-based healthcare professionals To ensure individuals health needs are properly assessed and met, in accordance with current guidance and legislation. 3 9 13 You must ensure there are 11/06/2009 robust arrangements for safe administration and recording of medication, particularly: Care Homes for Older People Page 10 of 14 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Systems to verify handwritten directions or alterations on medication administration sheets (such as staff signing and dating entries); Where a variable dose is prescribed, recording what has been given; Systems for monitoring the shelf-life of medication, including skin creams; Ensuring people receive prescription only medications only when they have been prescribed for them To ensure peoples medication is managed safely and effectively. 4 29 19 You must not employ people 11/06/2009 to work at the care home unless you have all of the information required under Schedule 2, including two satisfactory written references and evidence of their qualifications (including their nurse registration status) To ensure people living at the home are protected from unsuitable people. 5 33 26 The registered providers representative must carry out monthly unannounced visits to the care home 11/06/2009 Care Homes for Older People Page 11 of 14 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To monitor the standard of care provided there and measure its success in meeting the aims, objectives and Statement of Purpose of the home. 6 38 13 You must ensure risks to peoples safety are eliminated where possible, by ensuring The correct handling equipment is used, as indicated in individuals care plans; Pressure-relieving equipment is used correctly, and as indicated in individuals care plans To protect the safety and welfare of people living at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 11/06/2009 1 8 It is recommended that an agreed range of acceptable levels for blood sugars be recorded in care plans, to ensure that staff are aware of the appropriate action to take should levels fall outside agreed levels. [Carried forward from last inspection] In order to store medicines correctly, you should ensure that maximum and minimum temperatures the fridge are accurately recorded. [Carried forward from last inspection] It is recommended that you review arrangements for Page 12 of 14 2 9 3 10 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations privacy with regard to some bathrooms or toilets, to help ensure peoples dignity can be respected when using these facilities. 4 19 It is recommended that you ensure risks to peoples safety are eliminated where possible, by reviewing storage of equipment so that fire equipment is easily accessible at all times, and seeking advice from the local fire authority. In order to ensure peoples safety, it is recommended that a full risk assessment be completed for the use of the portable ramp, to ensure that risks are identified and reduced where possible. [Carried forward from last inspection] To promote good infection control, it is recommended that hand gel is provided in the toilet without a hand sink on the first floor. [Carried forward from last inspection] It is recommended that you ensure all staff use correct procedures for control of infection, including use of protective clothing and safe handling of clinical waste and dirty laundry. It is recommended that visits carried out in compliance with Regulation 26 are in line with the CQC guidance on such visits, available from our internet site. It is recommended that staff are appropriately supervised, both through regular 1:1 sessions as well as during their daily work, to identify any training needs and promote or maintain good standards of care. 5 22 6 26 7 26 8 33 9 36 Care Homes for Older People Page 13 of 14 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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