Care Home: Castletroy Residential Home

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What the care home does well The inspection indicates that the home is being well managed. Residents expressed a good deal of satisfaction in respect of the quality of service they receive. Their views including those of staff and visiting relatives have been reflected throughout the report The assessment and admission processes for new residents are good, thus ensuring that their identified needs could be met on admission. The health and personal care needs are clearly woven in the care plan for each resident; these are being monitored internally through a monthly review system. ‘I have been asked to contribute to my care plan’ said a resident. The standard of care seen was good; staff members treat residents with dignity and respect – ‘Extremely polite and patient in their approach, if you ask’, reflected a visiting relative. During the inspection, the main meal was being served and staff members including the cook were present in the dining rooms to support residents. All residents spoken to said the food provided is good and plentiful. The dietary requirements of residents are being appropriately met. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.2 The residents were well presented physically and appeared well cared for. A hairdresser visits regularly and residents appeared to value this facility very much. Contacts with family and friends are encouraged and well supported. ‘Always plenty of activities to keep us happy’, said a resident. The staff members on duty appeared very committed and positive, and felt well supported. They were enthusiastic about their work, and said that they have a good level of training to enable them meet the needs of the resident group. NVQ training for staff is being progress well. What has improved since the last inspection? There has been significant improvement made since the last inspection visit in August 2008. The implementation of requirements arising from that visit has resulted in an improved quality of service and safety for residents. Residents admitted to the home now have a comprehensive needs assessment undertaken at the initial stage of the care to be delivered. The resident is consulted about the intended care to be implemented; the care plan is signed by the resident and/or their representative, as appropriate. Risk assessment reflects the level of risk to the resident and this is kept under review. The procedure for disposal of gloves has been reviewed, in order to ensure residents’ safety. Staff members ensure that all equipment used for residents is in good working order. A call bell facility is now available in all residents’ bedrooms. The procedures for dealing with residents’ finances have been reviewed and improved. This ensures that appropriate receipts and recording of all transactions are maintained to safeguard residents’ financial interests. A new system has been introduced to ensure individual training and future development plans are available for all staff. A quality assurance system is being implemented to seek the views and experience of residents and other stakeholders, with a view to improve the quality of service delivery. What the care home could do better: There are 2 requirements and 2 recommendations arising from this report; these need addressing. Remedial action must be taken so that all fire doors shut on their rebate in accordance with fire regulations. This is to ensure the safety and protection of residents (A previous requirement).Castletroy Residential HomeDS0000015033.V378016.R01.S.doc Version 5.2 A monthly report must be produced for visits made under Regulation 26 of the Care Homes Regulations and a copy must be kept at the home. This is so that the manager can take action as required. Recommendations: The monthly review minutes should be in greater details, in order to provide a reasonable audit trail of relevant changes and current objectives for health and personal care for each resident, over a month period. Arrangements should be made to ensure that residents are provided with keys to their bedrooms, unless their risks assessment suggests otherwise; the care plan should reflect the reason for this. Key inspection report CARE HOMES FOR OLDER PEOPLE Castletroy Residential Home 130 Cromer Way Luton LU2 7GP Lead Inspector Key Unannounced Inspection 8th October 2009 10:10 DS0000015033.V378016.R01.S.do c Version 5.3 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. Castletroy Residential Home DS0000015033.V378016.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 Castletroy Residential Home DS0000015033.V378016.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 castletroy@btconnect.com Castletroy Home Mrs Jacqueline England Care Home 70 Category(ies) of Old age, not falling within any other category registration, with number (70) of places Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 70 27th August 2008 Date of last inspection Brief Description of the Service: Castletroy is a purpose built two-storey home situated on the outskirts of Luton. The home is registered to accommodate up to 70 residents over the age of sixty-five, 8 of whom may also have physical disabilities. Castletroy Home is the registered provider Single room accommodation is available for each resident with en-suite toilet and washbasin facilities. There are communal lounges and dining rooms on both floors. 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 passenger lift is available to access the first floor. There are spacious and well-maintained gardens to the front and rear of the home. Public transport and amenities are easily accessible. A copy of the last inspection report, service user’s guide and an information pack is available in the reception area, for residents and visitors to read. The fee for this service is £481.37, per resident per week; the exact fees are reflected in individual service agreements for the residents. Castletroy Residential Home DS0000015033.V378016.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. We, the Care Quality Commission, undertook this unannounced key inspection of this home on 8 October 2009, the last having occurred on 27 August 2008. We spoke with 7 residents, 4 visiting relatives and 1 professional, the manager and 2 senior supervisors and 6 staff members including the head cook. The visit also provided an opportunity to observe staff care practices; medication administration was checked and a range of documents the home must keep, was viewed. We also undertook a brief tour of the home. At the time of the visit, there were 70 people in residence, with no vacancies. We have received the AQAA (Annual Quality Assurance Assessment - a document, which gives the manager the opportunity to tell us how well outcomes are being met for people living in the home); it provides good details about the service. We have also received surveys from 14 residents and 9 staff. The manager was available throughout the inspection. What the service does well: The inspection indicates that the home is being well managed. Residents expressed a good deal of satisfaction in respect of the quality of service they receive. Their views including those of staff and visiting relatives have been reflected throughout the report The assessment and admission processes for new residents are good, thus ensuring that their identified needs could be met on admission. The health and personal care needs are clearly woven in the care plan for each resident; these are being monitored internally through a monthly review system. ‘I have been asked to contribute to my care plan’ said a resident. The standard of care seen was good; staff members treat residents with dignity and respect – ‘Extremely polite and patient in their approach, if you ask’, reflected a visiting relative. During the inspection, the main meal was being served and staff members including the cook were present in the dining rooms to support residents. All residents spoken to said the food provided is good and plentiful. The dietary requirements of residents are being appropriately met. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.2 Page 6 The residents were well presented physically and appeared well cared for. A hairdresser visits regularly and residents appeared to value this facility very much. Contacts with family and friends are encouraged and well supported. ‘Always plenty of activities to keep us happy’, said a resident. The staff members on duty appeared very committed and positive, and felt well supported. They were enthusiastic about their work, and said that they have a good level of training to enable them meet the needs of the resident group. NVQ training for staff is being progress well. What has improved since the last inspection? What they could do better: There are 2 requirements and 2 recommendations arising from this report; these need addressing. Remedial action must be taken so that all fire doors shut on their rebate in accordance with fire regulations. This is to ensure the safety and protection of residents (A previous requirement). Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.2 Page 7 A monthly report must be produced for visits made under Regulation 26 of the Care Homes Regulations and a copy must be kept at the home. This is so that the manager can take action as required. Recommendations: The monthly review minutes should be in greater details, in order to provide a reasonable audit trail of relevant changes and current objectives for health and personal care for each resident, over a month period. Arrangements should be made to ensure that residents are provided with keys to their bedrooms, unless their risks assessment suggests otherwise; the care plan should reflect the reason for this. 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. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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.V378016.R01.S.doc Version 5.3 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): Standards 1, 2, 3, 5 & 6 People using the service experience good quality outcomes in this area. Information is available about the home to help residents decide if it is where they want to live. Residents’ needs are assessed to ensure that they can be fully met on admission. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA informed us that ‘Each resident has an individualised pre-admission assessment to ascertain whether the home can meet their needs, if they feel they cannot, then an explanation of why is given to the proposed resident’. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 10 There is a service user’s guide and a statement of purpose that provides information about the home’s facilities and services. A copy of the guide and an information pack is kept in the resident’s room. Staff interviewed reported that a member of the management team visits the prospective resident to complete an assessment of needs, in order to establish if the home is suitable for them. Case files examined for 5 residents indicate that pre-admission assessments had been undertaken in all cases. Assessment records are signed and dated as appropriate. Evidence shows that information about the prospective resident is also sought from their representative, health and social care professionals where necessary. There is good documentary evidence to demonstrate that the prospective resident and their representative are encouraged to visit the home and meet with staff and have a meal with the other residents, as necessary. Five residents spoken to confirm that they or their relatives had visited the home before moving in. ‘My son visited the home first and then I joined him on his second visit’, reported one resident. They also complimented the management team for taking time to show them around and explain how the home operates. Each resident is issued a contract that, although basic, does state the terms and conditions of their stay at the home. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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): Standards 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. Individual care plans detail the support needs of people living in the home, and how these needs should be met ensuring that the people are treated with dignity and respect. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA informed us that ‘We have improved our care planning systems to ensure a person centred approach, given training to senior staff in how best to document care delivered to ensure that all aspects of what is being delivered is also recorded. We have care plans and risk assessments in place to identify Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 12 those at risk of pressure damage and what action is being taken to reduce the risk, for example, pressure relieving equipment’. Care files for five residents were examined. These include the initial assessment information, care plans, daily records, review notes, health records and any other relevant information. The care plan is developed with contribution from the resident, their representative and home staff. Information from care plans, residents and staff members indicates that the needs of residents are being identified and addressed satisfactorily. The care plan indicates how the identified needs are to be met. The care given, progress made and interactions with other residents are recorded at the end of each shift. Identified health needs are also recorded in the resident’s files, and evidence was seen of professional consultation with a range of health professionals, including GP’s and district nurses, continence advisor and dietician. ‘Staff are helpful and I have no concerns’, said a visiting health professional. Care plans are reviewed monthly to reflect the changing needs and objectives for health and personal care. Review minutes are being maintained and they also reflect the signature of the resident and their representative where appropriate. However, monthly review minutes should be in greater details, in order to provide a reasonable audit trail of relevant development for each resident, over a month period. Risk assessments are completed for each resident and these are reviewed as and when required. The home has a suitable policy and procedure on medication, which has been reviewed in 2009. Only members of the management team are authorised to administer medicines and they have all receive training on this subject. Records including receipts and storage, administration, and disposal of medicines are in good order. Residents spoken with said that they receive their medication on time. ‘I receive all my medicines regularly’, reported one resident. Staff members on duty were seen to deliver care and attend to residents’ needs in a sensitive manner that very much respects their privacy, dignity, choice and wishes whilst actively promoting their independence. ‘I wouldn’t hesitate to live here when I am older’, said a visiting relative. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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): Standards 12, 13, 14, & 15 People using the service experience excellent quality outcomes in this area. The social, cultural, religious and recreational interests of residents are being well addressed. The quality and variety of food offered is of a good standard. This means that residents’ welfare is being well promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA informed us that ‘We have employed more activities staff, thus enabling a one to one programme on a weekly basis for those residents who either cannot or who do not like to leave their rooms. The home continues to offer a wider range of activities’. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 14 The home offers a high standard of activities for people using the service. Two full time activity coordinators and one volunteer are available to assist residents participate in a wide range of social and recreational activities to suit their needs. The home has an activities room and a record of all residents’ likes and dislikes is maintained. Activities programme is in place that incorporates the choices of most of the residents. Interaction is also provided for people who choose not to participate in activities. There is evidence to demonstrate that people are consulted about what activities they prefer to be involved in. Comments from residents spoken to and surveys are very positive. Comments include ‘I participate in activities such as ball games, reminiscence and I love entertaining my visitors’, ‘I particularly like discussions and reminiscence; always something to do’, Various things fill my day’ and ‘Couldn’t ask for more activities’. Responding to a survey question ‘if the home arranges activities that you can take part in if you want?’, 13 residents said ‘Always’ and 1, ‘usually’. Relatives are encouraged to be involved in the residents’ lives as much as possible and all relatives spoken to said they can come to the home whenever they liked. All 4 visiting relatives spoken to made many positive comments. Examples include, ‘Residents are always busy in some form of activities’, ‘My relative enjoys the activities offered here’ ‘They’re perfect and lovely and I’m very happy with them’ and ‘Staff are always helpful and friendly, and will answer any questions we may have’. The home also has a hair dressing salon and some people choose to have their own hairdressers to come to the home. The home has three monthly residents meetings and residents are encouraged to make decisions on what they would like to see, including activities. Social contacts with family and friends are very good. Relatives also have six monthly to yearly meetings. Issues regarding equality and diversity including culture and religion are being well addressed. People are encouraged to make decisions over their own lives. Some residents have personal telephones in their bedrooms. Some residents choose to have their meals in their bedrooms and this is well facilitated by staff members. The menu is varied, wholesome and nutritious. There is a choice of main meal offered for lunch and tea, including the option to have something different from the advertised menu. Discussion with the head cook and care plans viewed clearly show that the dietary and cultural needs of the resident, as well as their taste and preference are seriously taken into account. Meals are offered at regular intervals and requests can be made for food at anytime. Hot and cold drinks are available at all times. Lunch was well presented; the cook takes pride in the quality, quantity and presentation of meals. Residents expressed a good deal of satisfaction regarding food offered to them. Examples include I’m very pleased with the food, if you ask’, ‘Food is nice’ and ‘Food is quite nice but some food is better than others’. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 15 The home received a 4 star rating for hygiene from the Environmental Health department in June 2009. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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): Standard 16 & 18. People using the service experience good quality outcomes in this area. Polices and procedures are in place to protect people living in the home from abuse, and to ensure any comments or concerns are listened to and acted on. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA states ‘The home has a clear and accessible concerns/complaints procedure illustrating timescales, and how complaints are dealt with’. The service has a complaints policy in line with the minimum standards, which ensures that if any complaints are received, they are dealt with in an appropriate manner and within set timescales. A copy of the complaints procedure is included in the service user guide, and a copy of the guide given to everyone living in the home. 4 of the 5 residents spoken to said that they are aware of the complaints procedure and would be able to raise a concern regarding any aspect of the service they receive. ‘If I have any concerns, I’ll talk it over with staff’, said a Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 17 resident. Surveys from 14 residents indicate that most of them know how to make a complaint. ‘I do not have any complaint but I’ll probably speak to staff if I had any concerns’, said a visiting relative. There have been no complaints received by the home since the last inspection on 27 August 2008; the Commission has not received any complaints regarding any aspects of the service during this period. Staff members said that they know what to do if they receive a complaint. The home’s procedure on adult protection is satisfactory. The “Whistle Blowing” policy is also available to the staff team. All staff members have received training in the protection of vulnerable adults. An element of this is included for those members who have completed their NVQ assessment. There have been 3 matters reported to the local safeguarding team since the previous inspection. The home staff appeared to have taken appropriate action, in order to protect residents. Evidence of POVA First and CRB checks is available on the staff’s files viewed, which also ensures residents’ safety. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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): Standards 19, 20, 21, 23, 24, 25 & 26. People using the service experience good quality outcomes in this area. The service provides a homely style of living in pleasant and clean surroundings, with well maintained gardens, accessible to residents. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We undertook a brief tour of the premises to include 13 bedrooms, 2 lounges, 2 dining rooms, library, hairdressing salon, conservatory, 3 bathroom facilities and the kitchen. All bedrooms have en-suite toilet facilities. The standard of decoration and furniture and fittings in those areas viewed is good. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 19 The home was kept fresh and pleasant and a high standard of cleanliness was evident. Residents spoken to said that the home was always kept clean and bedrooms are satisfactorily furnished and comfortable. They also said that they were happy with their bedrooms and that they are able to bring their personal possessions and belongings. Evidence of furniture, mobiles and other personal effect brought by residents was seen in the bedrooms viewed. The inspection report dated 27 August 2008 noted that most bedroom doors were proped open and as a result some did not shut on their rebate. We were informed by the owner and manager that costing has been completed and arrangements are in hand for the work to completed by December 2009. This would ensure that all doors shut on their rebate in accordance with fire regulations so that residents are protected. Residents are not offered a key to their bedroom unless they ask for it. This is not acceptable; the resident should be offered a key to their bedroom unless this is not appropriate; for example their risk assessment suggests otherwise; in this case the care plan should reflect the reason for this. The conservative is very attractive. There are spacious and well maintained gardens to the front and rear of the property, which is well used during the warmer weather. Evidence shows that staff have undertaken training in infection control. Protective clothes and gloves and hand washing facilities are provided. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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): Standards 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. A well trained team of staff are available to support the people living in the home at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA tells us ‘All staff receive induction training and regular updates.The home has an appropriately qualified workforce with at least 50 of staff delivering personal care holding an NVQ level 2 or above’. An established staff team is in place to ensure the needs of people living in the home can be met. During our visit, we looked at staff rotas, and observed staff on duty in the home. There are sufficient care staff employed to meet the identified needs of the individuals living in the home, together with a range of ancillary staff including the catering team. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 21 All 6 residents and 4 visiting relatives spoken with confirm that they consider the staffing levels to be appropriate; they are also very positive about the quality of service offered at this home. Example of comments from residents include: ‘I have no problems with staff’, they’re perfect and lovely and I am happy with staff’ and ‘They are very good and kind’. Recruitment procedures remain robust. Recruitment files examined for 5 staff members including the latest recruit shows that the necessary checks and information are all in place; this include application forms, at least two written references, POVA First and CRB (Criminal Records Bureau) checks, training records and health declarations. Staff members receive mandatory training such as Moving and Handling, Fire Safety, First Aid and Food Hygiene. Training specific to the people they look after include Catheter Care, Diabetes, Oral and Pressure Care, Parkinson, Bereavement and Mental capacity Act and Deprivation of Liberty. Surveys from 9 staff indicate that they are very positive about how their training needs are being addressed. Comments include: ‘There are relevant training running through out the year so everyone has the opportunity to access training’ and ‘All the necessary training is offered’. Of the 48 care staff, 17 hold an NVQ level 2 or equivalent qualification. Another 17 members have enrolled for NVQ level 2 or 3 course. One senior supervisor has enrolled for NVQ level 4. It is evident that training is being given a high profile and this investment in staff would ensure an improve quality of service delivery for residents. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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): Standards 31, 33, 35, 36, 37 & 38 People using the service experience good quality outcomes in this area. The home is well managed and run in the best interests of the residents. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager has been managing this home for the previous 5 years. She has completed NVQ Level 4 in Management and Care; she also holds a professional qualification in nursing. She has received training in the Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 23 Mental Capacity Act. She clearly has the knowledge, experience and skills to run a home for older people. Staff and residents told us that the manager is always helpful. One staff describes management support as approachable, friendly, helpful and very supportive’. There is good evidence that the manager is discharging her responsibilities fully and to good effect. An annual survey seeking the views and experience of residents and their representatives regarding the quality of service offered at Castletroy Home has been introduced by the manager; this was last completed in March 2009. The outcomes of the survey are displayed in the main entrance area for the benefit of residents and visiting relatives and professionals. Evidence shows that the provider visits the home weekly, in order to ensure that appropriate standards are being maintained. However, monthly visit reports were not available for the recent months; the owner is aware that this is required under Regulation 26 of the Care Homes Regulations 2001 and he has agreed to take remedial action. Regular weekly meetings are held between the manager and the registered person, and the manager confirmed that she is well supported. The manager has the support of 2 able senior supervisors who ensure that care and staff management systems including health and safety are coordinated and implemented effectively. Staff receive regular supervision of their working practices and details of their supervision sessions are maintained. All staff members attend in daily handovers at the home. Observation of care practice during the visit also demonstrates that staff and residents enjoy a good relationship. We looked at some of the records the home is required to keep; these were found to be order. Comprehensive policies and procedures are available and accessible to staff. The procedures for dealing with residents’ finances have been reviewed and improved. Health and safety procedures are in place to ensure that the people living or working in the home are not placed at risk, and regular maintenance checks are carried out. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 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 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 3 3 3 X 3 2 2 4 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 4 X 2 X 3 3 3 3 Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 25 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 OP25 Regulation 13 (4) & 23 (4) Requirement Remedial action must be taken so that all fire doors shut on their rebate in accordance with fire regulations. This is to ensure the safety and protection of residents (A previous requirement). A report must be produced for visits made under Regulation 26 of the Care Homes Regulations and a copy must be kept at the home. This is so that the manager can take action as required. Timescale for action 20/12/09 2. OP33 26 02/11/09 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 OP7 Good Practice Recommendations The monthly review minutes should be in greater details, DS0000015033.V378016.R01.S.doc Version 5.3 Page 26 Castletroy Residential Home in order to provide a reasonable audit trail of relevant changes and current objectives for health and personal care for each resident, over a month period. 2. OP24 Arrangements should be made to ensure that residents are provided with keys to their bedrooms, unless their risks assessment suggests otherwise; the care plan should reflect the reason for this. Castletroy Residential Home DS0000015033.V378016.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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