Inspection on 13/08/08 for Catchpole Court Residential And Nursing Home

This inspection was carried out on 13th August 2008.

CSCI found this care home to be providing an Good service.

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... 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... 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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Catchpole Court Residential And Nursing Home Walnut Tree Lane Sudbury Suffolk CO10 6BD Lead Inspector Mary Jeffries Unannounced Inspection 13th August 2008 2:15 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.V370198.R01.S.doc Version 5.2 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.V370198.R01.S.doc Version 5.2 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 catchpole.court@craegmoor.co.uk www.craegmoor.co.uk Speciality Care (REIT Homes) Ltd Miss Victoria Ann Hemsworth Care Home 66 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (43), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (2), Old age, not falling within any other category (20) Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The conditions are as follows: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age not falling into any other category - code OP (maximum number of places: 20) Service users with Dementia who are over 65 years of age - code DE (E) (maximum number of places: 43) Service users with Dementia who are under 65 years of age - code DE (maximum number of places: 1 - for named individual) Service users with a mental disorder who are over 65 years of age code MD (E) (maximum number of places: 2 - for named individuals) 2. The maximum number of service users who can be accommodated is 66 Date of last inspection 18th May 2007 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 residents. Gainsborough House accommodates up to 37 older persons with a diagnosis of dementia, Constable House accommodates up to 29 older persons, some of whom are physically frail and some have dementia who are best cared for on this unit. At the time of the inspection, the home was awaiting the outcome of an application so that the numbers of residents in each category are not restricted. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 5 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 residents. Good car parking facilities are available for visitors. Current weekly fees commence at £701 based on assessment of need, including the nursing element. Fees for residents whose nursing element is paid for by the Health Authority start at £600 per week. Social Care Services are able to access a limited number of places for frail elderly residents at weekly fees of £380 and for residents with dementia at £495, a Health Authority payment of £101 is paid in addition to this. The fees do not include hairdressing, chiropody, daily newspapers, toiletries or clothing. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. The inspection was unannounced and took place over six hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. This included a completed Annual Quality Assurance Assessment (AQAA). Surveys were sent to a team of local professionals but no responses were received. Five relatives provided pre inspection surveys prior to the inspection. The manager and the deputy manager helped facilitate the inspection, four members of staff and three relatives contributed. There were no vacancies in the home on the day of the inspection. Four residents were tracked; two of these were spoken with, two did not wish to speak. A group of four residents were spoken with about matters CSCI surveys cover, and another resident were spoken with in privacy. A number of records were inspected including those relating to residents care plans, residents finances, complaints, staff personnel and training, medication, quality assurance and polices and procedures. In addition to requirements made at the last inspection, issues that had previously been found to be of concern, but which had been found to be addressed at the last inspection were also inspected in some detail. This was with a view to establishing whether improvements found at the last inspection had been maintained. What the service does well: The home is well managed, has improved significantly and has commitment to further improvements. Residents can expect to have their needs assessed before a placement is offered, and therefore be confident that the home can meet their needs. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 7 Care plans consider all aspects of residents needs, and identify individual requirements; partially as a consequence of this staff have a good knowledge and understanding of residents’ needs. Daily life is enjoyable for residents in the home, and the meals are good and well appreciated. Some rewarding and stimulating activities are provided, for people with dementia that provide them with opportunities to produce expressive and impressive artwork. Staff training is up to date in all mandatory areas. The home provides an attractive safe and clean environment that is geared to meet the needs of residents, and their finances are properly safeguarded. What has improved since the last inspection? What they could do better: Two requirements were made. The frequency and content of supervision needs to be improved. Risk assessments relating to restraint must be discussed with the family or an involved professional and countersigned. The home’s AQAA identifies the following aspects of provision as being what they could do better; ongoing development of the person centred care plans, to continue to improve activities offered; to continue with regular resident and relatives meetings and to further involve the service users and their representatives in the running of the home. All of these areas were found to be acceptable, but it is an indication of the home’s aim to continue improving that they have identified these areas. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 9 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.V370198.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be fully assessed prior to being admitted to the home, and be confident, that if they are offered a place that the home can meet their needs. EVIDENCE: All five relatives who provided a pre inspection questionnaire indicated that they thought the home always or usually gives them enough information about the home to help them make decisions. The Manager advised that the Service User Guide and Statement of Purpose are one document, and were in the process of being updated so that they reflected the anticipated change to registration. A copy of the working document was provided. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 11 The working document was not yet complete, in particular charging information needs to be included; the home confirmed the charges information that will be included in the document immediately after the inspection. Residents had copies of the last Service User Guide in their rooms. New pre-admission assessment forms have been introduced. These include a section for capacity to consent, but do not specifically provide a section to establish if there has been a diagnosis of dementia, which would be helpful to ensure that this is always established. The files of two recently admitted residents were seen. Both had been assessed prior to admission, and both had their diagnosis clearly indicated on there assessments. Both of these people had been admitted from hospital and had not visited prior to admission. One of them was spoken with, they advised that they were told about the home. They and their spouse advised that they were very pleased with the home so far. The Statement of Purpose states that pre admission visits are available and the manager confirmed that this was the case. The AQAA confirms that the home does not provide Intermediate Treatment. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their health and personal care needs identified and regularly reviewed, and to be satisfied that they will be met. EVIDENCE: All five relatives who provided a pre inspection questionnaire indicated that they thought the home always or usually meets the needs of their relative, and also that the care home meets the different needs of people. A new person centred care plan format had been introduced, which contained a range of good information, including nutritional assessments and tissue viability assessments. The files of the residents inspected had good care plans which had been regularly reviewed. A Regulation 37 quality control report had been received by the CSCI in January 2008. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 13 This stated that a full review of care plans by the manager was to be undertaken to ensure that service user’s individual needs are identified and appropriate care plans in place to meet the individual needs and wishes of service users by 31st Jan 2008. There was evidence on the files inspected to demonstrate that this had been undertaken. Two of the residents tracked had bed rails; they had risk assessments for these on their care plans however these had not been counter-signed by the family or by a doctor. Both of the residents did require these bed sides. One of these people had been discharged from hospital with them, however, the consent of a relative or medical practitioner should be sought for a person who is unable to consent to these themselves, to ensure that people are not unnecessarily restrained in their movements. The administration of teatime medication was observed. Proper procedures were followed. The nurse undertaking medication had a good manner and was patient with residents, returning to them if they initially refused. They had a good knowledge of residents and their needs. An audit was taken of controlled drugs in the home. Records and stores were found to be in good order. The home undertakes its own audit of medication once a month. The records of the last audit dated 8th June 2008 were inspected. This identified five missing signatures for medicines in a one-week period. Against each one, there was a note that the member of staff was to be spoken with. In the inspection these records were cross-referenced with supervision records. There was no record of the matter being discussed in supervision, even though three of the gaps were attributable to one staff member and two to another. This is a very small number of errors in proportion to the number of medications administered in a month, less than 0.25 , however ongoing improvement requires this to be followed up. Files inspected showed that residents received a range of input from other medical professionals, including dentists and opticians and chiropodist, and also input from specialist teams such as the speech and language team, who had been involved with the assessment of a resident who was identified as having a choking risk. A survey respondent noted; “My (relative) entered the home in March and so far I have been satisfied and pleased with what I have seen.” All of the five relatives who provided questionnaires indicated that the home always or usually met the individual needs of their relative. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a good quality of daily life, and to have opportunities to join in meaningful activities. EVIDENCE: A relative’s survey noted that when their spouse went into hospital the home could not have been better at keeping them informed. Four of the five relative surveys indicted that the home always keeps them informed and up to date with important issues affecting their relative, but the fifth noted that when they ‘phoned to enquire how their relative was, they only got a comment, “(they) are well, (they) have eaten well, (they) are fine. Two relatives of one resident who were spoken with at the inspection and advised that their relative had been admitted quite recently and that they were very happy to know their parent was in this home. They visit very regularly, felt welcome, and were pleased that the home supported them in participating in the care. All of the relatives who provided questionnaires to us stated that they were always kept up to date with issues affecting their relative. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 15 All of the residents spoken with confirmed that the home provided good food and alternatives. Comments about the food in the home were very positive. They also spoke about being able to choose when they go to bed and what they do during the day. The home has two activity worker posts. A range of activities is offered. There is a well-equipped activities room. An art worker attends the home on a weekly basis. Around the home were examples of residents work; some of the artwork displayed in the special need unit was very attractive, and demonstrated high levels of expression that the residents with dementia are capable of. Activity baskets were available on both units. The home had recently held a summer fete for residents and relatives, and raised monies for further amenities. As noted under management a cultural afternoon involving staff and their families had recently been held. The cook was spoken with, they advised of a range of special diets that they prepare. Full details of resident dietary needs and preferences were maintained in the kitchen, and fresh fruit was available in the home. Menus showed a good range of well-cooked meals and fresh vegetables were available. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that complaints will be fully investigated and that the home will make proper referrals to the Statutory Authorities where this is appropriate. EVIDENCE: Four of the five relative surveys indicated that they know how to make a complaint, the fifth indicated that they didn’t, but in response to the query “Has the care service responded appropriately if you or the person living their has raised a concern?” they replies that it had, but “slow to get done.” One of the others noted that they had never had to make a raise a concern, the other three indicted that the home always or usually responded appropriately when they had raised concerns. The policy for complaints was displayed in the home. The home maintained a complete record of complaints. A number of complaints had been received, all had been fully looked into and properly responded to. A number of adult safeguarding referrals had been made during the year. The home had made some of these referrals, and had done so properly. In one case, the home had issued a written warning to a member of staff, rather than dismissal, and had full records of why this action had been decided. The manager advised that the member of staff had since performed their duties well. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 17 The company has an internal system of reporting concerns and incidents upwards to the responsible individual, which means that decisions regarding reporting and action are not taken solely within the home. Staff spoken with had a proper understanding of adult safeguarding. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a homely, clean and safe environment that has been adapted to improve the quality of their lives. EVIDENCE: Prior to the inspection the home had confirmed the receipt of a substantial grant from Social Care Services, and had kept us informed on the progress of works being undertaken. A tour of the home and the gardens was undertaken. It was seen that an enclosed sensory garden, for the benefit of residents with dementia, had been completed, and that the redecoration on Gainsborough Unit had included the provision of features that appeal to residents sense of touch and hearing as well as sight, and many pictures and feature that have a link to the past, making it a stimulating environment for residents with dementia. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 19 On both units, an old fashioned “sweet shop” had been fashioned, with large attractive displays of candies reminiscent of the 1950s and 60s. These are not just displays, residents are able to visit and get sweets. Individual rooms had identifying features, which assists residents with dementia. The sensory garden was well equipped, attractive an interesting, it featured mobiles and perfumed plants. Two of the doors from Gainsborough which open directly on to the garden were unlocked, and residents have direct access to the garden. The garden is enclosed by a low fence, it is at the front of the building and visible from the office. Some bathrooms in the home have been upgraded and put back into use. The lounge area on Constable unit had also been refurbished, and was homely and comfortable. Vanity units in resident’s bedrooms which had damaged surfaces had all been replaced. Carpets in the two stairwells were in good condition. There remain some areas in the home that have yet to be upgraded, but the condition of these was acceptable, subject to the redecoration/renewal cycle continuing, for example one upstairs corridor carpet, and some remaining individual rooms. The AQAA notes that continued refurbishment is required. Hot water temperatures were taken at a number of outlets during the tour of the environment and were found to be satisfactory. The maintenance worker was able to provide records of testing being undertaken on a regular ongoing basis. During the tour of the environments, cupboards and rooms which are to be kept locked for safety reasons were tested and found to be locked. The door to the small back yard, which is not accessible to residents, was properly locked. As we had been notified, the office doors were now on an auto closure, so they could remain open to visitors and residents but close safely and instantly in the event of a fire alarm. The room of a resident who is reliant on oxygen had a notice on the door, as is required. The home was clean and uncluttered, and there were no unpleasant odours anywhere. There were appropriate gloves and aprons available in the home and paper towels available in all bathrooms inspected. A sluice room was inspected, it was orderly and mops were appropriately stored. The District Council inspected food safety in the home on 4th June 2008; a copy of the report was forwarded to CSCI. The report commented that they found a well-run premises; two requirements and one recommendation were made. The home was required to ensure that all kitchen staff have level 2 NVQ or basic hygiene training as is stated in the home’s food safety management system manual, and to address the matter of water from the steamer underneath it. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 20 It was recommended that the food safety management system was adapted to require the smoothie maker to be washed by hand before being placed in the dishwasher. The kitchen was briefly inspected; the steamer was out of commission pending repair. The cleaning of the smoothie maker had been added to the food management system. One member of kitchen staff involved in cooking had been enlisted to undertake NVQ 2. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be well cared for by a well-trained staff group who are employed in sufficient numbers and who have a good understanding of their needs. EVIDENCE: Two relatives added comments to the survey query as to whether care staff had the right skills and experience to look after people properly. Both comments made were positive; one noted, “On what I have seen when visiting my wife I would say yes”, the other acknowledged that they only had short visits so didn’t see a much of what goes on, but noted that staff seem to know what they are doing. The home was well staffed on the day of the inspection. Rosters were inspected and this was found to be consistently the case. Both units always have a nurse on duty, wherever possible two nurses rather than one were covering day shifts on one of the units and the manager advised that she was trying to establish this as complement. No new staff had been recruited in the last year. Employment practices had previously been found to be good. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 22 The files of two workers who were due to start work at the home shortly, one the following week, were inspected. These were found to have all of the required documents as is required under the regulations. A schedule of training provided in the home was inspected, and this was crosschecked with evidence of training on two workers files. All of the mandatory training and training update had been provided to staff. A member of staff spoken with confirmed that they were enjoying working at the home and that the atmosphere had improved. They had a good knowledge of resident’s needs. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a well managed home where their health and safety is protected. EVIDENCE: The home’s AQAA notes strong leadership as an aspect of provision at the home that has improved. Vicky Hemsworth has been registered with the CSCI as manager of the home since the last inspection. She had provided us with a satisfactory improvement plan after the last inspection, and kept us up to date with progress on this during the year. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 24 The responsible person for the home has also maintained good communication with the CSCI, and the manager advised that she is confident in the support she receives from the Responsible Person. It was evident at the inspection, that as well as achieving some significant improvements in the home, that she had achieved this whilst also developing staff morale and improving the atmosphere within the home. All but one of the requirements and recommendations made at the last inspection had been met. Improvements found at the last inspection had been maintained. The home has a large staff group who come from a range of different cultural and ethnic backgrounds. The manager advised that they had recently had an event where staff and their families and residents and their families attended, and staff brought in favourite dishes that represented their culture for the residents to try. (Staff were reimbursed for the cost of provision). A member of staff described this event as a great success, and a resident also confirmed that this hade been a very enjoyable event. Another member of staff spoken to advised that the home seemed like a happier place. One relative who provided us with a pre inspection survey commented; “There seem to be improvements going on all of the time to make the place better and a happy home.” A number of good quality assurance systems and exercises had been put in place across most aspects of service provision in the home. Clinical Governance audits continued, the last of these was undertaken in January 2008. This report was inspected, a thorough process had been undertaken and the outcomes were good. There were records of regular Regulation 37 visits having been made to the home, and there were records in the home of residents and relatives meetings. The electronic records of residents’ finances were available. These were supplemented by a paper record, which meant that the most recent transactions that had not yet appeared on the central system were also available in the home. Records were inspected for the residents tracked, and for one other (as the home did not hold records for one of the residents tracked) Both sets of records were found to be consistent with each other and to accurately detail a number of appropriate transactions. Regular payments of small amounts of interest into each account were documented. The transactions detailed were backed by receipts. Records showed that regular supervision had been put on line for staff, including individual supervision and group supervision. Some of the supervision had slipped form the two monthly schedule, and as noted under the Health and Personal Care section of this report, there is scope for better follow through in supervision of matters identified in practice. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 25 Without regular formal one to one supervision staff development will be limited, and residents cannot be assured that any aspects of caring and nursing needing improvement will be followed through and worked on. No shortfalls regarding health and safety were identified in the course of the inspection. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 26 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 X 3 X X N/a 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 13(4) Timescale for action Where bedrails or any other form 30/09/08 of restraint are in place, risk assessments must be countersigned by a relative or external professional, for example a G.P., to ensure that decisions regarding restraint are made on the basis of proper consultation. Formal supervision must take 30/09/08 place in line with the home’s policy, and sufficiently regularly to support and monitor staff. This is a repeat requirement from the inspection of 18/05/2007. Requirement 7 OP36 18(2) 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 OP3 Good Practice Recommendations Pre admission assessment forms should include a section in a prominent position to state whether the prospective DS0000024351.V370198.R01.S.doc Version 5.2 Page 28 Catchpole Court Residential And Nursing Home resident has a primary diagnosis of dementia, as this is a major factor in determining their needs, and it will ensure that this is always addressed. Catchpole Court Residential And Nursing Home DS0000024351.V370198.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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