Inspection on 13/04/05 for Catchpole Court Residential And Nursing Home

This inspection was carried out on 13th April 2005.

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... 10/02/06

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

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 Walnut Tree Lane Sudbury Suffolk CO10 6BD Lead Inspector Mary Jeffries Unannounced 13/04/2005 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Catchpole Court Residential & Nursing Home Address Walnut Tree Lane, Sudbury, Suffolk, CO10 6BD Telephone number Fax number Email 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 cmdellhm@nbol.co.uk 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18th August 2004 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on one afternoon in April 2005, and the inspector was present for three and a half hours. Mrs Sue Carter has been appointed by Speciality Care (REIT Homes) Limited To be Manager, however she is not yet registered with the CSCI, and is referred to within this report as Acting Manager. Mrs Carter took part in the inspection. She had been in post for approximately four months. The home had an adequate number of staff employed on the day of the inspection, but a total of eight shifts were being covered by agency staff on that day. What the service does well: What has improved since the last inspection? What they could do better: Catchpole Court Version 1.10 Page 6 Service users can expect to find that the home has suffered from the home having had 3 managers within the last two years, and a 5 month period when the home had an acting manager. This is reflected in the number of requirements made, and repeated. Whilst some aspects of the environment had improved, there were a number of environmental issues that had not been fully dealt with. Two requirements made at this inspection related to matters previously identified had implications for hygiene, and health and safety. The home has had difficulties with localised odours over a long period of time, and a requirement has been made in respect of this in the last 7 inspection reports. Varying reasons, and remedies have been put forward, but a concerted effort must be made in all fronts, care practices, soft furnishings, air fresheners, cleaning to eliminate this problem. Recruitment practices, and maintenance of records of this must be maintained in the home. Service users lives are likely to be enhanced by a review of staffing rotas, a full staff compliment that lessens the dependency on agency staff, and additional specialist training in dementia. Catchpole Court Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Catchpole Court Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Catchpole Court Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 4 Service Users can expect to have access to an updated Statement of Purpose, which includes all necessary information. Service users on the dementia unit cannot expect all of their carers to have received specialist dementia training at present. EVIDENCE: The Statement of Purpose had been found, at the previous inspection, to lack information about individual room sizes, and how they met the standards. The Inspector was provided with a copy of an insertion into the Statement of Purpose, detailing individual room sizes. The manager stated that apart from an input of 3 hours training with 8 staff, a programme of specialised dementia training had not yet been implemented. They advised that a meeting had been held to discuss the implementation of a two day specialised training course for all staff working on the dementia unit. Catchpole Court Version 1.10 Page 10 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 standard(s) 7, 8, 10, 11 Service users can expect to have a thorough personal care plan care plan that sets out their personal and social care needs, and for this to be regularly reviewed. They can expect their health care needs to be met, and to be treated with respect. EVIDENCE: All interactions witnessed between staff and service users were appropriate, relaxed and friendly. One service user said that the best thing about the home was that everyone was kind. Another service user who had been in several homes, and acknowledged that they had thought there to be some “patient – staff communication problems in all of them”, confirmed that staff attitudes at Catchpole Court were “alright”, and favourable compared to a hospital they had been in and one other care home. Catchpole Court Version 1.10 Page 11 Storage of continence products and other clinical products within service users’ bedrooms was discreet. The crockery available at Gainsborough House was new, and of good quality, but was made of a synthetic material. Four service users care plans were inspected. Health care needs had been met, and records of appointments with health care professionals recorded. Two of these service users were known by staff to have had MRSA. In one of these this was detailed in the care plan, in another this was not present, and the care plan section on this was empty, although there was evidence that the home had consulted with public health, and specific control of infection measures were in place. A record of the dates of admission, unit providing care, cause of death, and date of death was provided by the manager in respect of a higher than average number of deaths that had occurred during the first three months of the year, and this was discussed with the manager. Care plans were generally well written, reviewed regularly and were up to date. Service users wishes, in the event of their death were recorded on care plans seen. Discussion with management and staff regarding the care practices at the end of residents’ life, involved good consultation with family and medical professionals. Catchpole Court Version 1.10 Page 12 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 standard(s) 12, 13, 14 Service Users can expect flexible routines and to have access to a range of activities. When Service Users are not taking part in a structured or organised activity, they may not receive as much attention to their social needs as they might wish. EVIDENCE: During a tour of the home it was apparent that many of the service users’ bedrooms were nicely personalised and included their own pieces of furniture. Service users spoken with confirmed that friends and relatives could visit when they wanted to and were often offered a cup of tea, and that their privacy was respected. Full and appropriate activities programmes were in place at the home. These were lead by the hobby therapist. There was also an activities worker who did one to one work service users. They were doing one to one work with a service user in the large lounge on the afternoon of the inspection. A service user who spent most of their time in bed, had isolation detailed as a need on their care plan, and had specific input to address this recorded. Catchpole Court Version 1.10 Page 13 They spoke, however, of wanting more attention from staff than they were receiving. A group of nine service users were observed sitting around the television set in the same lounge at the same time. Several were dozing, two appeared to be focusing on the TV. Others were sitting quietly, not engaged in any activity. The TV had children’s cartoons showing, and when asked if they were enjoying it none responded. Catchpole Court Version 1.10 Page 14 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 standard(s) 16,18 Service users can be assured that staff who are concerned about their care or safety are aware that they must report this, and will be properly protected if they do so. Service users may reasonably expect that any complaints they or their relatives make will be responded to. Employment practices, and record keeping do not currently demonstrate that service users are protected from abuse. EVIDENCE: A copy of the home’s Whistle Blowing Policy was seen, and had been extended to include staffs responsibility to report bad practice or suspicions of abuse, and right to employment protection under the Public Interest Disclosure Act 1998 when highlighting these matters in good faith. Service users spoken with felt that they could complain of they needed to, one stated that they had complained about a problem with communication and something had been done. A file containing records of complaints recorded outcomes and processes. No log of complaints was maintained, so it was not possible to ascertain whether all complaints received had been dealt with. Lack of evidence of CRB, PoVA first check or references on one of three staff files viewed. Catchpole Court Version 1.10 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 standard(s) 19,23, 24, 25,26 Service users can expect ongoing maintenance and decoration to take place, but may find that some matters are missed, not attended to, or not fully resolved in a timely way. Service users can expect to have an individual room which is personalised and which meets their needs. EVIDENCE: A tour of the building was undertaken, including a number of service users’ rooms. The repair and decoration schedule was discussed with the manager, but was not available for inspection. At previous inspections it had been identified that a number of carpets required replacing or cleaning. The carpet of one, but not both, of the bedrooms previously identified, and several others were seen to have been replaced. The manager advised that half a dozen had been replaced. Catchpole Court Version 1.10 Page 16 The home was found to be generally clean, but there was a faint lingering smell of urine in two of several resident’s rooms that were checked. One of these rooms, 42, was a room that had previously been identified as requiring the carpet to be changed, it had not been and the provider had advised the CSCI that the odour was considered to result from care practices, not the carpet. At the time of the inspection the home manager advised that they were trying out a number of different types of air freshener. The home provided an action plan indicating that it intended to replace the carpet in the stairwell in Constable Unit by 31st October 2004, and liaise with the manufacturer of the carpets in corridors in Gainsborough unit, to seek replacement. These carpets were seen not to have been cleaned sufficiently or replaced at the time of the inspection. Bedrooms 25,26 and 27 were identified at the last inspection as lacking sufficient natural light, due to the growth of trees outside of these rooms. Rooms The home had agreed to send an action plan to the CSCI, in respect of how sufficient natural light is to be provided within these rooms: this had not been provided. The Manager advised that a surveyor had recently visited the home to consider the lack of natural light in these bedrooms and had advised that the only way to achieve more light in these rooms was to put in skylights. Devices to automatically close the doors in the event of a fire had been fitted to some bedroom doors, where service users wished to have their bedroom doors open. However, one service user spoken with, whose door was on a heavy closure not fitted to the fire alarm, had a heavy ornament propping the door open which they said they usually used. The manager advised that lockable drawers had been provided to all residents as was advised in the homes action plan following the previous inspection, as far as they knew. A locked drawer was seen in one service users room, but not in another, room 5, which is on the frail elderly unit, and the service user advised that they do not have anywhere to lock anything up. The manager advised that the maintenance worker maintained a list of running repairs. Catchpole Court Version 1.10 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 ,29 Service users lives are likely to be enhanced by a review of staffing rotas, a full staff compliment that lessens the dependency on agency staff, and additional specialist training in dementia. EVIDENCE: There were no staff to be found easily when the inspector arrived at the home. The maintenance man was found and went to fetch a senior member of staff. When the manager arrived, she advised she had been absent due to taking a service user to hospital. Staff rotas for 26th March to April 22nd, a staffing list and a record of agency staff were inspected and staffing was discussed with the Acting Manager. Documentation showed that considerable use was being made of agency staff. On Gainsborough, three were deployed on the day of the inspection, two of whom were working double , i.e. 12hour shifts. The one agency worker who was scheduled for a single shift on that day, was scheduled to work a double shift the following day, and an early shift the day afterwards. On Constable, two agency staff were deployed on the day of the inspection, one of these working a double shift. The rota indicated that a large number of shifts were covered by agency staff and staff employed at the home were still working a high number of long (12 hour) shifts. Catchpole Court Version 1.10 Page 18 The staffing list provided showed that the home had had two nurses and six care staff less on its books than at the time of the announced inspection in August 2004. The manager advised that the home was currently 400 care hours down on the staff compliment. Some shifts were covered buy overtime rather than agency workers, however, the home was seen to be adequately staffed in terms of numbers on the day of the inspection. Recruitment is dealt with centrally by the registered providers. Staff files for three members of staff were inspected. There were no references, CRB Check or PoVA first Check on one of these. The missing documentation was in respect of a worker who started work in the home in October 2004. The manager confirmed that these could not be found at the time of the inspection. Two staff were observed transferring a service user into a wheel chair using a lifting belt, demonstrating a competent and kind manner. The manager advised that specialist dementia training had not yet been fully implemented, and that only 3 hrs, plus homework had been delivered to 3 staff. The manager confirmed that she was looking to implement two full days to all staff on Gainsborough unit. Catchpole Court Version 1.10 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 38 The recently appointed manager had made a positive start at the home. Stability had been provided by an assistant manager who acted as manager between appointments, but a number of requirements made at the previous inspection had not been met. EVIDENCE: The homes current manager had taken up post in January 2005. No application had been received for the Manager to be registered at the time of the inspection. Prior to this the home had been without a Registered Manager since July 2004. That previous manager was only in post for approximately one year. One of the staff members spoken with offered the view that when current manager said something was going to be done, it was done. Another said that the new manager was interested in her work, understanding, and supportive of them developing activities. Catchpole Court Version 1.10 Page 20 The new manager had taken on supervision herself, and had a record of 25 of staff having received a supervision session. One service user said that in their opinion staff were sometimes “not mature in the way they went about things”, and clarified this by stating that “they would benefit from management do some more field management, to stand and quietly watch how staff went about things.” No fire drills were recorded in the fire log book. The manager confirmed that no fire drills had taken place. The fire log book showed that fire training had occurred on 17/04/05, and the manager informed the inspector that it was also occurring on the day of the inspection. A recommendation made at the previous inspection, that consideration should be given to attending to a potential risk by relocating the kitchen’s washing up area to a safer place to avoid kitchen staff having to cross a corridor, had not been responded to. The manager advised that this was a low priority. The general atmosphere within the home, throughout the afternoon of inspection was calm. Catchpole Court Version 1.10 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x 3 2 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x 2 x 2 Catchpole Court Version 1.10 Page 22 YES Are there any outstanding requirements from the last inspection? 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 4 Regulation 10(1) & 18 Requirement The staff team working at Gainsborough House must undertake specific training in working with people with dementia. Care plans must details all aspects of health, personal and social care needs. The carpet on and around the stairwell on Constable House must be replaced. The carpets in the corridors within Gainsborough House are kept free from unsightly stains. If this is not possible then the carpets must be replaced. Suitable lockable storage facilities are made available to all service users. 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. The home must employ an appropraite number of staff with an appropriate skill mix to meet service users needs consistently. The home must be kept free from unpleasant odours. This Version 1.10 Timescale for action 31.12.05 2. 3. 4. 7 19 19 15(1) 23(2) (b,d) 23(2) (b,d) Immediate and ongoing 31.09.05 31.09.05 5. 6. 24 25 23(2)(m) 23(2)(p) 31.08.05 31.08.05 7. 27 18(1)(a) 31/09/05 8. 26 16(2)(k) 31/08/05 Catchpole Court Page 23 9. 18,29 10. 31 11. 36 17(2) Schedule 4(6), 19 (1)(b)(i) Schedule 2& 19(1)(c) Care Standards Act 2000 Section 11 17(2) Schedule 4(6)(f) & 18(2) requirement is repeated from the last six inspections. Evidence of References and a Immediate Criminal Records Bureau check, and or Pova First check obtained ongoing before commencing work at the home is required on file. An application must be made for the homes Manager to be Registered. All staff must receive formal supervision at a recommended frequency at not less than six times per year. Minutes of these meetings must be kept on file and made available for inspection. Fire drills must be held at appropraite intervals Fire doors must not be propped open. 31/08/05 31/09/05 12. 13. 38 38 23(4)(a) 23(4)(e) Immediate and ongoing. Immediate 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. 3. Refer to Standard 12 16 19 Good Practice Recommendations Service Users social and recreational needs should be promoted by all staff throughout the day. A complaints log should be maintained A schedule of renewal and repair, detailing repairs/replacement needed and done to the fabric and decoration of the building , and timescales, should be kept, in line with agreements made by the provider, and is subject to QA. A review of 6 and 12 hour shift patterns should be completed and any findings implemented. Further consideration should be given to relocating the kitchen’s washing up area to a safer place within the care home, in order to avoid kitchen staff having to cross a Version 1.10 Page 24 4. 5. 27 38 Catchpole Court corridor from the kitchen to the washing area. Catchpole Court Version 1.10 Page 25 Commission for Social Care Inspection CSCI, 5TH Floor, St Vincents 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 Version 1.10 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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