Care Home: Castleton Lodge Care Home

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What the care home does well Information about services provided by the home is good, it is available to those people who use the service and provides enough information for them to be able to decide if the home will be suitable for them. People receive a robust assessment before moving into the home. They are also consistently offered the opportunity to visit and look around as well. People live in an environment that gives them safety and security. Positive relationships were seen between them, and people reacted in a positive way. People`s bedrooms have been furnished to meet their individual needs and tastes, and many areas in the home are tastefully furnished and well equipped. Robust policies and procedure for the smooth running of the home are in place and reviewed regularly. The interests of the people living in the home are the main concern of the manager. Peoples` dignity is respected and staff are well aware of respecting people as individuals. People and their relatives are involved in the day-to-day running of the home through meetings and being asked their opinions. One relative said "The manager and staff discuss all issues and are very informative". What has improved since the last inspection? The care planning and assessment process has developed with the introduction of the Care and Health Assessment Profile. (CHAP). The staff are more aware of the complaints and whistle-blowing procedures. The Home Manager operates an "Open Door Policy and is easily accessible for staff out of hours. The exterior of the home has been totally redecorated. The company have introduced a "Verify and Check System" which informs all the homes of any Medical Alerts, Health and Safety issues and response time. Automatic door closures are being fitted on the bedroom doors on a rolling programme. A refurbishment budget has been allocated to the home to improve various areas.Castleton Lodge Care HomeDS0000044491.V376762.R01.S.docVersion 5.2The staff team has increased in numbers so the home has reduced the usage of agency staff so continuity can be maintained where possible. They have lower sickness and absence levels and these are monitored. Staff retention has improved alongside this, which has increased staff morale as they have a more stable workforce. The home now has a full time permanent Home Manager and a full time permanent Administrator who have forged a good working relationship. What the care home could do better: The care records should clearly show the weight of people who uses the service and what action has been taken by staff to ensure dietary needs are addressed to prevent serious consequences to their health. The care plans for people with dementia should say how it affected them and how staff could help them. There should be more information about people`s social care needs to show that people get the stimulation they require. People should be given the required assistance to eat their meal, and more staff interaction is required when feeding people. Some system should be put in place for who is feeding who and a system needs to be adopted to ensure that everyone has had a meal and drink. The manager should make sure that all members of staff have regular formal one-to-one supervision sessions. This will made sure that staff are supported and supervised to carry out their role. Key inspection report CARE HOMES FOR OLDER PEOPLE Castleton Lodge Care Home Green Lane New Wortley Leeds LS12 1JZ Lead Inspector Hebrew Rawlins Key Unannounced Inspection 27th July 2009 08:30 DS0000044491.V376762.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castleton Lodge Care Home Address Green Lane New Wortley Leeds LS12 1JZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 231 1755 0113 231 9789 castleton@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd Vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability (2), Terminally ill over 65 years of age (1) Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The place for TI(E) is for the service user specified in the NCSC letter dated 17 December 2003. The places for PD are specifically for named service users Date of last inspection 31st July 2008 Brief Description of the Service: Castleton Lodge Care Home is a detached purpose built property located in Armley, which is on the outskirts of Leeds. The home is owned and managed by Four Seasons Health Care Ltd. The property is set in its own grounds with ample car parking facilities available at the front of the premises. There is a bus service along the main road; people can register with the Access bus, which will drive up to the home. The home is owned and registered to Four Seasons Health Care, as a care home with nursing for up to 60 older people, 30 of which have Dementia or related mental health problems. The accommodation consists of 60 single rooms, all of which have en suite facilities. There are 8 communal lounges, as well as a large reception area for people living at the home to use. There are two dining rooms and a central kitchen. There are five communal bathrooms, two showers and eight communal toilets. Castleton Lodge Care Home DS0000044491.V376762.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 2 stars. This means the people who use this service experience Good quality outcomes. A visit was made on 27th July 2009 from 08:30 to 17:20. The home did not know that this was going to happen. The inspection was conducted in the company of the manager who had only worked at the home for 8 months. Feedback was given to her at the end of the visit. The purpose of the visit was to assess what progress the home had made in meeting the requirements made in the last inspection report and the impact of any changes in the quality of life experienced by people living at the home. Before visiting the home the inspector asked for information from the manager (the Annual Quality Assurance Assessment – AQAA) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information obtained from people who use the service, relatives, staff and other health care professionals. A tour of the home was carried out. At the time of writing this report, the fees charged for care provided were £402.57 to £608.00 per week. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 6 What the service does well: Information about services provided by the home is good, it is available to those people who use the service and provides enough information for them to be able to decide if the home will be suitable for them. People receive a robust assessment before moving into the home. They are also consistently offered the opportunity to visit and look around as well. People live in an environment that gives them safety and security. Positive relationships were seen between them, and people reacted in a positive way. People’s bedrooms have been furnished to meet their individual needs and tastes, and many areas in the home are tastefully furnished and well equipped. Robust policies and procedure for the smooth running of the home are in place and reviewed regularly. The interests of the people living in the home are the main concern of the manager. Peoples’ dignity is respected and staff are well aware of respecting people as individuals. People and their relatives are involved in the day-to-day running of the home through meetings and being asked their opinions. One relative said “The manager and staff discuss all issues and are very informative”. What has improved since the last inspection? The care planning and assessment process has developed with the introduction of the Care and Health Assessment Profile. (CHAP). The staff are more aware of the complaints and whistle-blowing procedures. The Home Manager operates an “Open Door Policy and is easily accessible for staff out of hours. The exterior of the home has been totally redecorated. The company have introduced a “Verify and Check System” which informs all the homes of any Medical Alerts, Health and Safety issues and response time. Automatic door closures are being fitted on the bedroom doors on a rolling programme. A refurbishment budget has been allocated to the home to improve various areas. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 7 The staff team has increased in numbers so the home has reduced the usage of agency staff so continuity can be maintained where possible. They have lower sickness and absence levels and these are monitored. Staff retention has improved alongside this, which has increased staff morale as they have a more stable workforce. The home now has a full time permanent Home Manager and a full time permanent Administrator who have forged a good working relationship. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Castleton Lodge Care Home DS0000044491.V376762.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 Castleton Lodge Care Home DS0000044491.V376762.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ needs are properly assessed before admission, making sure their needs can be met. EVIDENCE: From the discussions with the manager and checks made of five files it showed that pre admission assessments are made before people come to live at the home. Three of the files checked were for three people who have been recently admitted. Written information like the statement of purpose and discussions with staff and people living in the home showed that all people considering living at the home and their relatives are seen personally and a visit to the Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 10 home is arranged when at least the relatives and if possible the prospective person using the service can see the room available and general facilities. Apart from the home’s own assessment documentation, other information is gathered from any social worker or healthcare professionals that have been involved. The home tries to get as much information about peoples’ lives, family, occupation, their preferred way of living including daily routines, hobbies and interests, personal care preferences, spiritual needs and food preferences. Relatives of people spoken with during the inspection said they had been given good information about the home before their relative moved in. They also said they had received a contract, records examined confirmed this. Castleton Lodge Care Home DS0000044491.V376762.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvement is needed to ensure the health and personal care needs of all people living in the home are provided for. EVIDENCE: There have been many positive comments made by people living in the home as well as their relatives about the care provided. Examples from two relatives spoken with include; ‘I cannot praise the staff enough for the care they provide’ and ‘the home keep me well informed’. Several people said ‘I am very happy living here’. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 12 We looked at the care files of six people living in the home. This involved looking at their care records and medication charts. The care plans provided useful information about how care needs were met and showed evidence of regular review. However there were some areas where improvements could be made in relation to health care needs. One care plan said ‘to be weight weekly’. However on examination of the record there was no evidence that the person had been weighed. The care records should clearly show the weight of people who use the service and what action has been taken by staff to ensure dietary needs are addressed to prevent serious consequences to their health. The care plans for people with dementia did not say how it affected them and how staff could help them. There was very little information about people’s social care needs to show that people get the stimulation they require. The care plans have details of any health professionals that people see. These include, GP, dentist, specialist nurse, and optician. Records are kept of any health appointments and their outcome. A GP, who returned a survey, commented that the home does well in providing excellent care to people, communicates well with the GP practice and gives people dignity. A relative visiting the home said, ‘They always respond well to medical needs but don’t panic unnecessarily and always keep you informed’. A record is kept in the home of medication ordered. This is checked against medication delivered and recorded as correct before any medication are dispensed. Photographs had been taken of people, which made sure they are clearly identified on the medication records. The medication administration record (MAR) sheets were checked and showed a few errors in administration. However the manager is addressing this. Care plans showed people are assured that at the time of their death, staff will treat them and their family with care and respect. Castleton Lodge Care Home DS0000044491.V376762.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People with dementia are not always provided with structured activity programmes that meet their needs. People living at the home are provided with a varied and nutritious diet. EVIDENCE: We looked closely at the care documentation of six people during the inspection. These showed that each person’s social interests are assessed at the beginning of their stay at the home. The home try to get families involved with writing pen pictures of their relatives. These help staff to understand the previous life history of the person they are caring for and what their likes and dislikes are in relation to things such as activities and food. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 14 The manager wrote in the Annual Quality Assurance Assessment that there is an experienced and enthusiastic Personal Activities Leader who has spent time developing life histories of people. Little evidence was found during the inspection that this was used to develop activities for people with dementia. We observed no activities provided to this group in the home during the inspection. Relatives expressed concerns about the provision of activities on the top floor. They said: “My relative can’t join in the activities, so she sits or walks all day” “There is very little going on here, mind you they can’t do much” “I don’t see much of what they do” People were observed as being unmotivated. People who could do for themselves seemed to receive more staff interaction than those who could not communicate their needs. Many were sat around in chairs with little interaction other than staff providing for a care need. One person spoken with felt that staff do their best with people living in the home and felt activities is one area that could be developed further. The AQAA stated that people at Castleton Care Home are offered a choice of where meals are taken and those with swallowing difficulties or a reduced appetite are given individualised diets with the support of staff. People were observed during mealtime. There were some very positive interactions seen between staff and people who needed assistance. Staff were being helpful and careful. Most staff explained what they were doing when assisting people and most people were given time to swallow mouthfuls before being offered another. However, the meal time was disorganised and did not have good outcome for everyone. Examples of poor outcomes were: - One lady was given her food whilst she was sleeping by a carer who woke her and asked if she needed help. She did not respond. The carer stood over her and gave her one spoonful and then walked away. The lady then went back to sleep. Another carer came to her and told her she is not eating then walked away. So she went back to sleep. The first carer came back woke her gave her gave her two more spoonfuls then went to attend to someone else. So back to sleep she went. This went on for sometime before her plate was removed and meal not complete. - One person was being fed in a task orientated way. There was no dialogue, the person being fed was just opening and closing her mouth on demand. - Another person became aggressive when a member of staff took away a spoon from her table to feed someone else. This interrupted her meal and she didn’t want any more. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 15 - One lady had her meal left in front of her then removed with hardly any food being eaten; despite being asked if she wanted it on a smaller plate. It seemed to us not everyone was being given the required assistance to eat their meal. From our observation more staff interaction is required when feeding people. There did not seem to be any system in place for who was feeding who. A system needs to be adopted to ensure that everyone has had a meal and drink. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at the home feel confident that they will be listened to and that appropriate action will be taken when necessary. There are adult protection procedures which staff have awareness of and understand and people can be assured that they can feel safe at the home. EVIDENCE: There is a clear complaints procedure in place and information provided in the self assessment form showed that the home operates a zero tolerance approach when dealing with complaints and adult protection (safeguarding) issues. People living at the home said that they were aware of the complaints procedure and would have no problem at all in approaching the manager or registered provider if they had any concerns about the standard of care being provided. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 17 The manager said all complaints are investigated using the home complaint procedure. However the manager should ensure that copies of the investigations report and outcome are kept. Adult protection policies and procedures are in place and training records provided by the manager show that staff have received training in the recognition and reporting of allegations of abuse. Feedback from staff indicates that they are aware of the home’s policy on “whistle blowing” and knew what to do if they suspected that people were being abused or working practices at the home were not in the best interest of the people living there. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home continues to provide people with a pleasant, safe and comfortable environment in which to live. EVIDENCE: A tour of the building was made. The home is warm, clean and furnished and decorated to a good standard. The cleaning staff work hard and are organised with their cleaning schedules. There are enough toilets and bathrooms to meet the needs of the people living there. People are encouraged to personalise their rooms and to bring familiar pieces of furniture in with them. The Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 19 bedrooms seen were comfortable and personalised. There is an ongoing programme of redecoration. Feedback from people living at the home and their relatives shows they are very pleased with the standard of accommodation. Comments included “the home is always kept clean and tidy” and both the bedrooms and communal rooms are nicely decorated.” Clinical waste is properly managed and staff wear protective clothing when attending to peoples’ personal care needs. Staff have received training in infection control and were able to say what infection control measures are in place. People spoke highly of the laundry service at the home. One person said “they do things very nicely”. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the home’s recruitment procedure and staff are supported in developing the skills and knowledge they need to care for people properly. EVIDENCE: The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two written references and a Criminal Record Bureau (CRB) before new staff start work. This makes sure people suitable to work in the caring profession are employed. Staff were observed to be confident in the roles they performed and the majority appeared to be confident and knew the roles they were expected to perform. Two members of staff said the training was good. Records confirmed that had received training in areas such as infection control, health and safety and Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 21 dementia training. However a number of staff training record files need updating. The manager said she is working on this. Five people spoken with said they felt ‘safe’ and a relative commented ‘I was assured that the staff received the relevant training to enable them to look after the people in this home and I think this is the case from the way they look after my mother’. Information provided by the manager said under 50 percent of staff have not completed the National Vocational Qualification (NVQ) at level two or above in care. The manager said the home is working hard towards this. In discussion with all persons they generally confirmed that the staff are good. Comments from them were, ‘good and helpful’; they get you what you want’. Relatives said ‘there is a good up beat atmosphere with the staff’ and some are very friendly’. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36, 37 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and the interests and health and safety of people at the home are, in the main, promoted and protected. EVIDENCE: Sue Smit was recently appointed manager of the home. She has many years experience in the caring profession and undergoing the registration process. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 23 Both the registered providers and manager have a positive attitude to the inspection process and have shown a willingness to work with us to maintain and improve standards at the home. The manager confirmed that she is well supported by the providers and there are clear lines of accountability, which makes sure the home is managed affectively and in the best interest of the people living there. The manager offers good leadership to the staff and has good systems in place to make sure people are supported and cared for properly. She has a great rapport with people living in the home and has good knowledge of their individual needs. One person said, “Nothing is any trouble for her, she is great”. Staff said “She is approachable and part of the team” and “She is very supportive, always got time for a word with you”. A number of staff have not received formal supervision for some time. The manager is aware of this and has plans in place to remedy the situation. The manager holds meetings with people living in the home, relatives and staff. Minutes of the meetings were seen and show that people are confident to share their views. The manager said she appreciates any comments or suggestions made if it means the service can be improved. Some people hand in money to the home for safekeeping. Records are kept of all transactions. The manager and administrator carry out regular checks of the money and the regional administrator also audits the system. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Maintenance records are kept. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. The manager has a system in place where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. The organisation’s yearly quality audit questionnaires give people, relatives and other care professionals the opportunity to give their views on the service provided at the home. The manager is looking at ways of letting people know the findings and actions of the audit. Information provided in the self assessment form shows that all equipment in use at the home are serviced in line with the manufactures guidelines, which means that people can be sure they are in good working order. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 x 2 3 3 Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP7 OP12 Good Practice Recommendations The care plans for people with dementia should say how it affected them and how staff could help them. This would help to ensure peoples’ needs are fully met. There should be more information about people’s social care needs to show that people get the stimulation they require. The care records should clearly show the weight of people who uses the service and what action has been taken by staff to ensure dietary needs are addressed to prevent serious consequences to their health. People should be given the required assistance to eat their meal, and more staff interaction is required when feeding DS0000044491.V376762.R01.S.doc Version 5.2 Page 26 3 OP15 4 OP15 Castleton Lodge Care Home 5 OP36 people. Some system should be put in place for who is feeding who and a system needs to be adopted to ensure that everyone has had a meal and drink. The manager should make sure that all members of staff have regular formal one-to-one supervision sessions. This will made sure that staff are supported and supervised to carry out their role. Castleton Lodge Care Home DS0000044491.V376762.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Yorkshire & Humberside Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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) Care Quality Commission (CQC). 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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