Inspection on 10/02/06 for Catchpole Court Residential And Nursing Home

This inspection was carried out on 10th February 2006.

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

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

Other inspections for this house

Catchpole Court Residential And... 13/08/08

Catchpole Court Residential And... 18/05/07

Catchpole Court Residential And... 26/01/07

Catchpole Court Residential And... 26/06/06

Catchpole Court Residential And... 02/08/05

Catchpole Court Residential And... 13/04/05

Catchpole Court Residential And... 18/08/04

Catchpole Court Residential And... 13/05/04

Catchpole Court Residential And... 20/02/04

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

CARE HOMES FOR OLDER PEOPLE Catchpole Court Residential And Nursing Home Walnut Tree Lane Sudbury Suffolk CO10 6BD Lead Inspector Mary Jeffries Unannounced Inspection 10th February 2006 10:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Catchpole Court Residential And Nursing Home Address Walnut Tree Lane Sudbury Suffolk CO10 6BD 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) 01787 882023 01787 378836 Speciality Care (REIT Homes) Limited Post Vacant Care Home 66 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (29) of places Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: Catchpole Court Residential and Nursing Home was built and first registered in 1991. Its current owners, Craegmoor Healthcare trading as Speciality Care (REIT homes) Limited, acquired the home in 1998. The home is located opposite to the Walnut Tree Hospital within a short distance of the centre of the small Suffolk town of Sudbury.The home is a large modern red brick building that is divided into two separate houses and can accommodate up to 66 service users. Constable House accommodates up to 29 physically frail older persons and Gainsborough House accommodates up to 37 older persons with a diagnosis of dementia. The home is built upon two floors with a shaft lift provided for access. Communal lounges, dining areas and conservatories are available for the use of the service users. Good car parking facilities are available for visitors. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on one day and early February2006. Two inspectors undertook the inspection and it lasted five and a half hours. Yvonne Goodard had been appointed by Speciality Care (REIT Homes) Limited to be manager, however an application for her to be registered has not yet been received by the CSCI, and she is referred to within this report as acting manager. The deputy manager also helped facilitate the inspection, and other staff participated. There were five vacancies at the time of the inspection; two on Constable and three on Gainsborough. One service user and a relative of another service user were spoken with, other service users were observed and spoken with more briefly. What the service does well: What has improved since the last inspection? Service users contracts correctly specified the rooms occupied. The complaints policy contained a timescale. The carpet in the stairwell on Constable had been replaced. The carpet on Gainsborough had been thoroughly cleaned. There was liquid soap available in all communal bathrooms, and no emollient cream was stored in them. All appropriate documents were on staff files. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 6 Supervision has taken place with staff and a programme set up so that this will meet the standard. A programme of NVQ training has been put on line. A programme of training in Dementia care has been implemented. A fire risk assessment was in place. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,6 Service users can expect to be provided with a contract that specifies the room they will occupy, and those with dementia can expect the home to be able to meet their needs. EVIDENCE: Three service users’ files were inspected for contracts; one, for a recently admitted service user had not yet been returned, the other two had contacts which included room numbers. Standard 4 was inspected fully at the previous inspection and one requirement was made: the home was required to provide training in dementia care for those working on Gainsborough unit. This had been put into practice. The acting manager confirmed that the home does not provide intermediate care. Standard three was found to be met at the previous inspection. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users can expect to have their needs set out in a plan, for staff to be aware of these, and for their health needs to be met. Service users are likely to find that working practices do not ensure that their privacy and dignity are maintained. EVIDENCE: Not all plans had appropriate risk assessments. Bedsides were being used for one service user, however, there was no risk assessment in respect of this, and no risk assessment was in place for one service user who had a lap belt on. Care plans were otherwise comprehensive, and were seen to be be regularly reviewed, although the new unit manager and the acting manager advised that they were looking to simplify them for ease of use. A full record of falls had been maintained. A record of pressure sores was maintained. It showed that in January, 2 of 36 service users on the dementia unit had a pressure sore, one having been admitted with the sore. On the elderly frail unit, 4 of 27 service users had sores, 3 having developed in the home. All reports indicated that a Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 10 wound protocol and care plan was in place. Records were available of visits from healthcare professionals. Monthly health checks were undertaken and recorded. Staff spoken with were generally aware of the needs of service users discussed. A new unit manager had recently been appointed to Gainsborough Unit. They were seen talking with a group of service users in a small lounge, including one of the service users who was being tracked. This manager was asked about some aspects of service user’s care on the unit, but had been so recently appointed that they were unable to assist not fully at this time. The relative of a service user who was not well and was receiving a high level of input said that the care itself was good. They said that when their relative first came to the home “it was a bit of an eye- opener” but that things had improved over the last two or three years, and more so recently. They described the staff as dedicated. This relative said there had been a language problem, with some foreign carers not being able to understand, but that there were only one or two now where communication was difficult. On the day of the inspection, the inspector asked one of the workers a simple question, and was advised that they did not understand. Medication records for the service users residing upstairs on Gainsborough were inspected. The records contained sample signatures, procedures for PRN medication, and waste disposal procedures. Service users records included photographs, date of birth, details of allergies, consent, and PRN protocols where applicable. Records were found to be in good order. Co-codamol was prescribed four times a day for one service user; it was not in a blister pack but in a separate box which had not been signed/dated when started. There was a record of an audit of medication undertaken by the acting manager in November 2005, and a score of 100 was recorded. The medication round on Gainsborough was observed. Medications were transported to the dining room on a suitable locked trolley. A service user’s nebuliser was seen, not fully put away in its case, under the chair of a service user in the sitting room in Constable. Staffs interactions with service users was observed and found to be appropriate and in some instances very good, they were polite, respectful and sensitive. Two service users spoken to spoke well of the carers. Staff were observed to be giving appropriate assistance with feeding on Gainsbourgh. A number of practices in the home, however, did not support dignity and privacy; these are documented elsewhere in the report and include, lack of secure storage for service users records, inappropriate use of records in communal areas, including bowel records, inappropriate and careless storage of incontinence pads. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users can expect their visitors to be made welcome, and to have a number of outings available to them. EVIDENCE: A service user spoken to said, “we like the place, there’s no doubt about it.” There were posters in the home of activities available, including an afternoon tea dance at a close local venue. Staff advised that quite a number of service users had decided to go to this. They also described a number of outings that had been arranged for service users for the coming year. Socialising was addressed in care plans seen. A visitor was spoken with. They explained that their relative was very poorly, but that they had become friends with another service user over the time they had been visiting, and on this occasion were sitting talking with them. The service user said that the best thing about living at the home was the visitors, and the visitor confirmed that they could visit whenever they liked. The acting manager described some initiatives that they had already undertaken to improve service users choices, and to ensure that their needs determined the routines, not vice versa. A service user was seen to have a lap belts in place whilst sitting in a wheel chair at the dining table. Staff were Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 12 asked about this and advised that this service spent most of his time in a reclining chair. Staff were asked about this practice and advised that it was employed with two other service users in reclining chairs. A nurse spoken to advised that one of these the service users had been risk assessed. The care plans for these two service users were inspected, neither were weight bearing, but there were no risk assessments associated with the use of a lap belts for one of these service users, and no record of when they were used for either of them. In the dementia unit there was a stair-gate. None of the service users residing upstairs on this unit were mobile, so this did not pose a restriction to them. One service user tracked had bedsides, and there was no risk assessment on their care plan to support this. Standard 15 was inspected at the previous inspection and found to be met, but it was recommended that the menu for the main meal each day, rather than the weeks entire menu, should be displayed prominently so that service users can know what they are looking forward to. The menu for the day’s meal was displayed prominently and clearly in the sitting room/dining room on Constable. The menu was also displayed in written form on Gainsborough. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users cannot be confident that all complaints will be responded to fully, and acted upon. EVIDENCE: The home’s complaints procedure and whistle blowing procedure were prominently displayed on a wall in the home. There was also a book in reception inviting concerns, it had no entries since November 2004. The complaints policy contained an appropriate timescale. The home had a set of papers relating to complaints, but there was no logbook, to clearly show outcomes. The last entry was August 2005, and the deputy confirmed that no complaints had been made since then. It was noted in the last inspection report that the home was dealing with a number of outstanding complaints at the time of the inspection. Two complaints, one of which had three elements and one of which had several elements were being investigated by the home. Both complaints had arisen in July 2005, and one was anonymous. There were no supporting papers to demonstrate that this complaint had been followed up by the acting manager. There was a common element in both complaints, and this was hygiene and cleanliness standards within the home. At the unannounced inspection undertaken on the 2nd August 2005, two requirements were made relating to cleanliness. The anonymous complaint Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 14 also referred to staffing shortages, although staffing levels were found to be adequate the inspection in August 2005. The other complaint which had been copied to the CSCI also had a number of concerns. These were focused on a carer’s attitude and alleged inappropriate restraint of a service user, but also included concerns about hygiene and cleanliness in the home, and care practices. Further elements relating to privacy and dignity, one of which was upheld, loss of the service users medication, unresolved, and the service user being bullied to eat a meal they did not want, not upheld. The investigation into the carer’s attitude and alleged inappropriate restraint was carried out by the provider in liaison with Suffolk Social Care Services, given the nature of the complaint. A need for training and close supervision was identified, and the worker was not put forward for inclusion on the Protection of Vulnerable Adults list. Social Care services accepted the recommendations made by the home, but wrote to seek reassurance on a number of matters related to the complaint, and had not received a response at the time of the inspection. Not all of the aspects of the complaint relating to hygiene had been responded to, although one had been accepted. Two other matters had occurred since the last inspection which involved Protection of Vulnerable Adults concerns. In both cases advice was given by the CSCI to refer the matters reported to customer first under vulnerable adults procedures, and the current acting manager had enquired about the process. One of these was in relation to a carer who was the subject of the complaint received in July 2005 detailed above, this carer left the home following an allegation of verbal abuse, and is no longer working there. It was evidenced at the inspection that the home had put into place a training programme which included Protection of Vulnerable Adults training for all staff, and challenging behaviour. Notices showed that some training in the Protection of Vulnerable Adults had occurred in January 2006, and that all staff would have received this by the end of the year. The acting manager confirmed that she is booked for PoVA Training in March 2006. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 Service users may get used to the pervasive smell of stale urine in the home, but in combination with the low standard of cleaning and the poor standard of decoration and paintwork on Constable unit in particular, and propped open fire doors, service users cannot expect a clean attractive or safe environment. EVIDENCE: Records of a health and safety meeting recorded that a new maintenance worker had been recruited; maintenance books were seen to be in place. The acting manager provided a “summary of General Conditions of Rooms”. This identified decorating requirements and a number of beds and vanity units that need replacing. The furniture in the dining room on Constable “mixed and matched” but was generally domestic in nature. The wall of the lounge diner area on Constable was used for staff notices, including training, general notices and the white board had workload allocations on it. A “Bowel book” was also on the cabinets Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 16 under the white board. Notices were pinned up with drawing pins, and were immediately above jugs of drinks, which were covered with paper serviettes. . A drawing pin popped out of one of the notices being inspected. There was one large plastic bin in this area. The dining room on Gainsborough was reasonable in terms of furnishings and facilities. Staff were observed sitting working at dining room tables with residents records, and one member of staff was doing the same whilst working sitting in the lounge with service users. The dining area was seen set for lunch, with tablecloths, place mats and serviettes. The standard of decoration was better on Gainsborough unit than on Constable unit, where much of the decoration in the home was tired, some doors scuffed and paintwork chipped, particularly in corridors and bathrooms. The carpet in the stairwell in Constable Unit had been replaced, the carpet in the corridors on Gainsborough looked sad and stained, but had evidently been cleaned and was in a better condition than when last seen at inspection. The home’s own list stated, “ all corridors in Constable need woodwork repainted, ¾ Gainsborough’s woodwork needs repainting. “ A number of service users who were in bed were seen in their individual rooms, including the wife of the relative spoken to. The rooms appeared to be adequately furnished. The homes own list of decoration required which was viewed at the end of the inspection identified cracks on or around ceilings in seven bedrooms, damp stains on ceilings in four bedrooms, decorating requirements in seventeen bedrooms. The decoration needs were discussed with the acting manager, who advised that she was concerned that some of the damage to woodwork related to the ways in which cleaning instruments were used and wheels chairs and hoists were moved, and that she planned to address this before having the decoration done. A separate maintenance plan was provided that gave a reasonable timetable within which the decoration needs identified were to be addressed. The environment on Gainsborough, however, did not have any particular modifications to support service user’s with dementia quality of life, for example, bedroom doors did not have meaningful identifying symbols or pictures, the day’s menu was written up but was not in photographic form. The outside gardens were seen to be in a reasonable state of maintenance for the time of year, but one area was seen where pavestones were damaged and needed replacement. These were not on the maintenance plan. Bathrooms were inspected and most were found to be tidy and uncluttered. but several in need of decoration. Towels were seen stored in a communal bathroom on Constable. Bathroom / toilet 4 on Gainsborough with a specialist Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 17 walk in bath had items stored within the bath, the wheeled frame of laundry bags. This was discussed with the acting manager who advised that this bath was not used. There was liquid soap and paper towels in all communal toilets and bathrooms. A window in an upstairs bathroom had been fitted with a window restrictor, but this was not functioning properly and the window could be fully opened. It was noted that some bathrooms had liquid soap and hand gel, but that the infection control policy did not give any reference to hand gel. This was discussed with the acting manager who said that they thought staff might have brought their own in. The ambient temperature in the small lounge off the main lounge/dining room on Constable was 20 degree Celsius, according to the thermometer on the wall. A service users spoken with said that they liked the temperature in this room, which was a summer room type construction with many windows, off the main lounge. The CSCI have required that an action plan be submitted in respect of how sufficient natural light is to be provided within rooms 25, 26 and 27. This requirement has been repeated twice, and has not been met. Two rooms were checked and found to be dark without electric light as a result of trees in close proximity, even though it was winter and the trees were relatively less of a barrier than at other times of the year. With the exception of the main kitchen, which was found to be very clean, the cleaning appeared not to be of a high standard. The acting manager advised that the kitchen staff did their own cleaning. Upon entering Constable, the smell of stale urine was immediately apparent. Cleaning standards on Gainsborough unit were better than on Constable, where the lounge dining area also had a strong smell of stale urine. A number of the W.C’s throughout the home had brown staining in the bottom of the bowls. A covered radiator on Constable corridor had thick dust on it, and the fire alarm had a cobweb on it. The acting manager advised that she had been struck by the smell when she first came to the home, but thought that it had improved. They advised that they were working to improve cleaning standards, and that a meeting had been held to address this but the notes of the domestics meeting did not evidence that this was being seriously progressed. The home had two service users with MRSA, an infection which can survive and hence spread in dust. In one small lobby on Constable unit, there was a door to both the front and back of the home. The door to the back had a notice to state “door alarmed, must not be turned off.” The door was not locked an it did not have an alarm when opened by the inspector. Outside of this door, there was some stacked materials, mainly washing detergents, but there was also a large bottle of “hygienic Cleaner” marked with a large black cross. A member of staff was asked to immediately put this into the Control Of Hazardous Substances (CoSHH) cupboard. The bottle appeared to have been outside for some time. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 18 Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service users can expect to have sufficient numbers of carers on duty, and to be safeguarded by the home’s recruitment practices. EVIDENCE: Standard 27 was inspected at the announced inspection and was found to be met. The home was adequately staffed on the day of the inspection. The acting manager was asked if the home currently had any staffing difficulties, and advised that they were now nearly at establishment, and had another worker they were waiting to recruit. A requirement had been made following the last inspection that the home must develop a strategy to achieve 50 of carers with NVQs, when it was found that only 25 of 32 carers has the qualification. A memo on the staff notice board stated that three staff had commenced NVQ 3, and two had commenced NVQ 2 in January 2006. a number of other care staff were due to start NVQs in April 2006, three at level 3, two at level 2. Four staff records were inspected and were found to contain, photographs, proof of identity, appropriate Criminal Record Bureau checks and references. One of them had not supplied a reference form their previous employer, but did have two references. The acting manager advised that she had prioritised setting up appropriate training since coming to work at the home. The deputy manager advised that Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 20 staff had three dedicated study days each allocated. The training file was inspected and individuals core training needs for 2006 had been identified. This included the elements of training that had been seen posted on Constable white board; Infection control, (3hrs), Manual Handling (4 hrs) Protection of Vulnerable Adults (3 hrs) Challenging behaviour (2hrs), Fire Safety (2hrs), Food hygiene (2 hrs), Health and Safety and Control of Substances hazardous to health (3 hrs). The notice board indicated that these had been arranged for January, and would be repeated in March, May, July, September and November. Core training also included infection control and equal opportunities. The deputy manager advised that they had taken on responsibility to coordinate training. Each employee had a training plan record that was completed annually by the deputy manager, who advised that any other training needs were identified in supervision. The training record indicated that domestics and kitchen staff all complete core training. The deputy manager advised that by the end of 2006, all staff should be up to date with their core training. Training records showed that eleven staff had completed dementia awareness training in October 2005. One of these eleven was a staff member whose file was inspected, and there was a certificate of attendance on their file. The training records also showed that two Registered General Nurses spoken with advised that they had recently started diplomas in dementia. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37,38 Service users cannot expect health and safety practices in the home to provide them with as full protection as they are entitled to. EVIDENCE: The home has not had a registered manager since August 2004, when the last registered manager left. A requirement had been made at the previous inspection that an application must be submitted to the CSCI for the manager to become registered. Since then, this manager had left, without being registered and another manager appointed. This acting manager had been in post for approximately 3 months. An application for their registration had not yet been received by the CSCI. The last inspection report was displayed in reception at the home. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 22 The acting manager was asked if they had conducted any quality assurance exercise. They advised that they had recently sent questionnaires out to relatives. The acting manager also advised that she had formed a view that under the auspices of dignity and choice, service users on the dementia unit’s daily routines in terms of when they went to bed and when they had their meals, service user’s needs had not always been put first. The acting manager advised that they had addressed care and training as priorities, and had on at least one occasion visited the home at 2am to observe care practices. They also advised that they had addressed daily living routines and bedtimes. They were asked if they had a written plan regarding how they were going to prioritise and tackle issues, and while the acting manager spoke of copious notes she had at home, she did not have a formal development plan. Standard 35 was inspected and found to be met at the previous inspection. Minutes of a number of meetings were maintained. These included unit meetings on Constable in November 2005, and unit meetings on Constable in November and January. A domestics’ meeting had been held in February. A list of monthly health and safety meetings was posted on the notice board on Constable, and records of meetings held in November and January were available. Within these minutes, many of the issues identified by the inspector were noted. The acting manager advised that regular supervisions had commenced. A staff file inspected showed that personal performance agreements for 2006 had been made, and that the January supervision had taken place. The notes of the meeting covered a wide range of issues. The deputy manager advised that all staff had a performance agreement in place. The home had a booklet detailing bi-monthly supervision and personal development plans. Service user’s care plans were kept on open shelves in the office. The acting manager was asked if this room was kept locked, and they advised it was not. Some, but not all of the service user’s files inspected contained property lists. In the kitchen, temperature records were maintained for the fridges and freezers. The hair dressing room was appropriately locked. Two fire doors were found to be propped open on Constable, and at the start of the inspection start on Gainsborough staff were overheard to say, “make sure that there are no fire doors propped open, the inspectors are here.” Fire extinguishers were seen to have been serviced in June 2005. A storage cupboard under the stair care on Constable was marked “fire door- keep locked.” This cupboard was seen to be used to keep equipment, it was not locked. This was discussed with the acting manager who was unsure whether it needed to be locked. The acting manager advised that the home had a fire risk Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 23 assessment, but it was not available in the home on the day of the inspection. It was forwarded to the CSCI immediately following the inspection. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 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 X 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 1 2 2 X X 2 2 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 2 2 Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 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 OP7OP14 Regulation 13(7), 15(c) Requirement Where the planned use of any form of restriction is practiced, it must be in line with an agreed risk assessment and measures agreed and signed by appropriate representatives. This is a repeat requirement. Records must be maintained of when restraint is used. Boxed medicines must be dated and signed when opened. Equipment for administering medicines must be properly stored to maintain required hygiene standards. Incontinence pads must be discretely stored in individual bedrooms and communal bathrooms. The use of restraint must be limited in line with the mental incapacity bill, which states that any restriction of liberty must be the shortest and least restrictive possible, and regard must be had that the purpose for which it is used can be achieved in any other less restrictive way. The homes complaints policy DS0000024351.V282816.R01.S.doc Timescale for action 10/02/06 2 3 4 OP7OP14 OP9 OP9 13(8) 13(4) 13(4)(a) 10/02/06 28/02/06 10/02/06 5 OP10 12(4)(a) 28/02/06 6 OP14 13(7) 10/02/06 7 OP16 22(3) 14/03/06 Page 26 Catchpole Court Residential And Nursing Home Version 5.1 8 9 10 11 OP18 OP18 OP19 OP19 12 13 14 15 16 OP19 OP19 OP21 OP25 OP25 17 OP26 18 OP26 19 20 OP26 OP26 must be consistently fully implemented. 13(6) The acting manager must undertake training in the Protection of Vulnerable adults 13(6) All staff must receive training in the protection of vulnerable adults. 23(2)(f) The communal dining/lounge area on Constable must not also be used as an office. 23(2)(d) The home must ensure the home is reasonably decorated throughout, in a reasonable timetable, and advise the CSCI if there is to be any delay to the maintenance plan provided. 23(2) (b, The carpets in the corridors d) within Gainsborough House must be replaced. 23(2)(o) Damaged pavestones in the garden must be replaced. 23(2)(n) Bathrooms should be kept available for use and not used as storage facilities. 13(4) A window restrictor in a first floor must be repaired. 23(2)(p) An action plan must be submitted to the CSCI in respect of how sufficient natural light is to be provided within rooms 25, 26 and 27. This is a repeat requirement from August 2005 . 16(2)(k) The home must be kept free from unpleasant odours. This requirement is repeated from the last eight inspections. 23,2,d,13, Cleaning standards must be 4,c,16,2,j improved. This is a repeat requirement, first made in August 2004. 13(3) To reduce the risk of the spread of infection towels must not be stored in communal bathrooms. 13(3) The home must address the use of hand gel in its infection control policy, whether it is to be DS0000024351.V282816.R01.S.doc 31/03/06 31/03/07 31/03/06 31/07/06 31/03/07 31/03/06 31/03/06 10/02/06 31/03/06 31/03/06 31/03/06 28/02/06 31/03/06 Catchpole Court Residential And Nursing Home Version 5.1 Page 27 21 22 OP28 OP30 18(1) 18(1) 23 24 OP31 OP33 CS Act 2000 Sec 11 24(1)(a) (b) 25 26 27 OP37 OP38 OP38 17(1)(b) (a) 23(4) 23(4) (c) used in the home, and the limitations of its effectiveness. The home must continue to work to achieve 50 of carers with NVQ2. The home must provide evidence that the planned training programme to ensure all staff have received core training has been undertaken by existing staff. An application must be made for the homes manager to be Registered. The home should have a formal plan for improving and reviewing the quality of care and nursing that includes consultation with service users and their representatives. Service users records must be securely stored. Fire doors must not be propped open. It must be established whether the cupboard under the stair well in Constable Unit is a fire door that needs to be kept locked, and appropriate action taken. 31/03/07 31/03/07 07/03/06 30/09/06 28/02/06 10/02/06 14/03/06 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 OP16 OP19 Good Practice Recommendations A log of complaints and outcomes should be maintained. The environment for service users with dementia should be developed to better meet their needs, with identifying features on individual rooms, and additional sensory stimulation. All service users rooms on the dementia unit should have photographs or identifying symbols on them. DS0000024351.V282816.R01.S.doc Version 5.1 Page 28 3 OP24 Catchpole Court Residential And Nursing Home 4 5 6 7 OP25 OP29 OP33 OP35 Staff should make a point of ensuring service users in the small lounge on Constable are warm enough. Where a reference from the previous employer is not available, the reason for this should e explored and documented. Service users should be asked if they have any views about staff working long shifts at the next service user survey. Property lists of service users valuables should include jewellery worn by the service user on admission, and should be signed. Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Catchpole Court Residential And Nursing Home DS0000024351.V282816.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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