Inspection on 18/05/07 for Catchpole Court Residential And Nursing Home

This inspection was carried out on 18th May 2007.

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... 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Catchpole Court Residential And Nursing Home Walnut Tree Lane Sudbury Suffolk CO10 6BD Lead Inspector Mary Jeffries Unannounced Inspection 18th May 2007 12:45 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.V341291.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.V341291.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 Speciality Care (REIT Homes) Limited Manager 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.V341291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 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. 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 residents. Good car parking facilities are available for visitors. Current fees are between £500 and £580, based on assessment of need, including the nursing element. Fees for residents whose nursing element is paid for by the health authority are £370.00 per week. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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. A random inspection was conducted on 23rd March 2007. A meeting was held with the Responsible Individual on 24th April 2007 to discuss the home’s registration and concerns about service shortfalls. A pre-inspection questionnaire was provided in February 2007. The inspection was conducted in the afternoon and early evening and took six hours. The deputy manager facilitated the inspection. A nurse and a number of care staff contributed. Given other sources of information available, the inspection focused on health and safety and health and personal care. There were no vacancies at the time of the inspection. Four residents were tracked, and the care plans and assessments of two recent admissions were inspected. What the service does well: What has improved since the last inspection? The home has an accurate and up to date Statement of Purpose that complies fully with regulations. Residents receive an up to date Service User Guide that complies fully with regulations, and includes a details of the complaints procedure, including timescales of response. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 6 Care records inspected included a full record of tilts and turns for residents who are mainly restricted to bed, and who require this intervention. A policy on death and dying was provided. A full record of complaints, including details of investigation and any action taken is now maintained in the home, and a system had been put in place whereby all complaints are also reported to the Responsible Individual. Provider monitoring reports made under regulation 26 evidenced that the records within the home were being monitored on a monthly basis, since the random inspection when this was found not to have been consistently the case. Evidence of interest paid into an account held by the company on behalf of residents had been provided prior to the inspection, as had been required. Hot water outlets had been maintained at or around 43 degrees Celsius. All bathrooms were inspected on this occasion and there was no evidence of bars of soap left in bathrooms, as had been found at the random inspection. Additional storage space had been constructed, although some of it was yet to be cleared and ready for use. Doors to walk in cupboards containing hot water tanks and un-lagged hot piping that are accessible to residents were found to be locked in accordance with the written instruction, and daily checks put in place. A linen cupboard with a door marked fire door keep locked which was not locked on the day of the unannounced inspection was found to be locked on this occasion. Work had been undertaken to comply with the requirements made by the Fire Officer in January 2007. The home had reduced its reliance on agency staff. The staffing compliment had been increased by one additional worker on early shifts on Gainsborough unit. Training in dementia had been undertaken by all staff, and a further two-day course had been provided for those working on Gainsborough unit. Training in the de-escalation of violence and aggression had been provided for twenty-two staff members. Management support and control of the home from the company has increased. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,6 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 have the information they need to make an informed choice about the home, and to be assessed prior to being offered a place. EVIDENCE: At the random inspection undertaken in March 2007, it was found that the Statement of Purpose had been amended since the previous key inspection and contained the required information. It showed clearly that nursing was provided. At that time, residents had loose-leaf folders containing the required elements of the Service User Guide in their rooms, and were referred to the availability of the latest inspection report which was kept in the office. On this occasion a copy of the latest inspection report was freely available in the foyer area of the home. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 10 At the last two inspections, a requirement had been made that the home must operate within its categories of registration, and apply for a variation immediately in respect of a number of residents who had a dementia diagnosis at the time of admission over and above the number that the home was registered to care for, and also two elderly residents with a diagnosis of mental illness. This matter was discussed at a meeting held with the provider at the CSCI offices on 24th April 2007. Some of the residents on Constable had been previously identified as having dementia, and were moved there from Gainsborough when their nursing needs had developed to such a level that they were better placed on Constable. On behalf of the company, the Responsible Individual accepted an imposition notice from CSCI which identified the existing numbers and categories of residents at Catchpole Court at the time. A new certificate was issued on 3 May 2007 to reflect that the home was registered to provide for a maximum of 66 residents (old age 20, older people with dementia 43, older people with mental disorder 2 and one resident under the age of 65 with dementia). A recently admitted resident appeared from the home’s assessment to fall outside of the categories of registration that the home had confirmed. The deputy manager advised that the resident required care on account of their dementia, however, this was not detailed on the pre-admission assessment. Immediately following the inspection the home provided evidence of a Dementia Diagnosis. The consultant psychiatrist’s letter stated that the resident’s unstable mood disorder was likely to be secondary to their atypical Alzheimer’s disease. The other recently admitted resident, who had come to live at the home two days prior to the key inspection, had a single assessment. The deputy manager advised that the home usually does their own assessment as well as this prior to admission, but that this was an emergency admission. The resident had a falls risk assessment conducted by the home. This deputy manager advised that key elements of the person’s plan had been completed, within 48 hours, in accordance with the home’s policy. The deputy manager confirmed the home does not provide intermediate treatment. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home is working to improve the level of health and personal care that they will receive, and that their welfare will be reviewed and monitored. EVIDENCE: The records for four residents were inspected. Nurses wrote a daily statement for each resident. It was noted at the random inspection that care notes had been changed to a tick box spreadsheet called a personal care activity sheet, which carers completed and the nurse on duty signed to show that it had been checked. In addition to this, residents who were bed bound had daily charts for fluid and turns. There was also a key worker audit sheet, to be completed weekly, which focused on a room check. This included items such as glasses (spectacles) clean, denture pot clean, correct incontinence products available. A requirement was made at the previous key inspection that full records must be kept of turns/tilts occurring, and that these must reflect the residents’ needs as laid out in the care plan. At Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 12 the random inspection, the records for two residents on Constable unit who were bedridden and had risk assessments for pressure areas were inspected. Neither had a pressure ulcer, however care records were incomplete, despite there also being a system of and quality control undertaken by nursing staff. Recording did not evidence that tilting and turning or checking of pressure areas had occurred as required by the care plan. Following this requirement, the home advised that a daily audit on 10 of the care documentation had been introduced. At this key inspection the care plans of three residents who were permanently in bed were inspected. Their records were complete, including full records of turns/tilts occurring, and also completed fluid charts where required. All of their plans had been recently reviewed, and were reviewed on a monthly basis. Appropriate pressure area care and equipment was in place. One of these people were spoken with, the other two were asleep. Their rooms were well aired and fresh, and they appeared comfortable. A nurse and a carer on the nursing unit advised, separately, that they only had one resident who had a pressure sore. The nurse had a good knowledge of the care needs of the residents. A large proportion of the residents were scheduled to have a six monthly medication review with their General Practitioner. The administration of medication was observed on Constable. All of the Medicine Administration records (MAR) sheets contained a photograph of the residents. At the beginning of the round the nurse used their bare fingers to remove a tablet from its packaging. This was immediately pointed out to them, and was not repeated. All of the MARs sheets inspected were complete and correct. The nurse advised that the home used to return unused medication to the pharmacy, but that these were now destroyed at the home using a kit. This was seen and the nurse described the procedure and the records kept. A stock check of controlled drugs was undertaken and these were found to be in order. At the random inspection, one resident who was bed bound and peg fed, however, advised that they thought that the staff manner was very poor, although they also added, “ to be fair, I think it has got a little bit better.” They were spoken with at this inspection, however, and did not consider that there had been much further improvement. On the day of the inspection, and of the previous random inspection, staff were seen and heard to be relating well to residents. No negative interactions were overheard. During the day, staff were seen and heard to be relating well to residents. The other resident who was tracked was observed wandering freely on Gainsborough. At one point another resident came up behind them another resident whilst singing, and startled them. The surprised resident “took a swing” at the other. Staff responded quickly but calmly, attending and diffusing Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 13 the situation, and not crowding the residents. One was led away by a relative who was visiting, and staff spent time calming down the resident who was equally startled by the others’ response. The resident had appropriate risk assessments care plans and behaviour management strategies in place. Incontinence pads have been found to be stored discretely in residents’ rooms at this, and the previous, inspection. Residents were observed closely at this key inspection and dress and personal hygiene was found to be satisfactory. A policy on death and dying was provided at the random inspection. At that time the home was supporting residents by allowing Room 11 to be used by the relatives of a very poorly resident at the time of the inspection. Catchpole Court Residential And Nursing Home DS0000024351.V341291.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect their relatives to be welcomed into the home and to enjoy their meals, but residents cannot be assured that staff will always be sensitive to and aware of the social needs of those with dementia. EVIDENCE: A carer spoken with advised that they thought that the food had improved, and that there were more choices. They advised that the next day there would be a choice of Place fillet or quiche. A residents spoken with said that the food was very good. Menus seen showed a good choice of food. A carer on Constable advised that their main opportunity to speak with residents was whilst they were assisting with getting them up, they advised however that there is a separate activities worker who provides some group activities and also spends individual time with residents who are most isolated. They advised that some resident have frequent visits from relatives, and were concerned about one resident where the frequency had declined. A resident spoken with confirmed that their relatives are always made to feel welcome. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 15 During the afternoon one resident with a dementia diagnosis indicated that they wanted to go outside, referring to the ways out and obstructions. A door from one room to the outside to the garden was open whilst a carer did some painting. Staff advised that residents were sometimes taken outside, but no one offered to facilitate this for the person concerned on this occasion, although the person persisted in seeking ways to go outside. The carer advised that a Pat Dog visited the home, and that communion was held at the home. Catchpole Court Residential And Nursing Home DS0000024351.V341291.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 thorough systems for responding to and monitoring complaints have been put in place, and they can expect these to be dealt with thoroughly. EVIDENCE: The current complaints policy was available to all residents. The policy summary with all the necessary information was displayed in the foyer; and the policy was within the Perspex files on the walls in residents’ rooms. A complaint that the CSCI had asked the provider to investigate was discussed at a meeting with the provider held on 24th May 2007. The responsible individual had cancelled two planned visits to the home to reinvestigate a complaint. They had attended the home on Tuesday 20th March 2007 to address this. The provider advised that in reinvestigating this complaint it was found that documentation had not been to an acceptable level, and disciplinary action had been taken against two members of staff. Paper work in respect of the complaint was subsequently forwarded to the CSCI. The Responsible Individual advised that changes had been made to the internal systems within the organisation, and that all critical incidents within the home were now reported to the company and that all complaints now have to go through the Responsible Individual. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 17 A full record of complaints, including details of investigation and any action taken is now maintained in the home. Provider monitoring reports made under regulation 26 evidenced that the records within the home were being monitored on a monthly basis. The responsible person also advised that an internal reporting form, a critical event form is now required in the event of a Protection of Vulnerable Adults referral. No PoVA referrals had been made since the last key inspection. A carer spoken with confirmed they had received PoVA training. Catchpole Court Residential And Nursing Home DS0000024351.V341291.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): 19,21,23,24,25,26, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there is still a need for refurbishment and redecoration in some parts of the home, residents can expect to find the environment clean. EVIDENCE: Residents live on two large units, which is not very conducive to a homely feeling, yet despite this the home is comfortable, clean and free from odour. Although areas of the home are now in good repair, a significant amount of refurbishment/redecoration is still required. In particular the lounge on Constable unit still requires decoration and refurbishment. The provider advised, following the random inspection, that decoration of the lounge on Constable was due to commence in April, however the, deputy manager advised that this whilst some work had bee done, this was to be done in Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 19 conjunction with other improvements to the dementia unit which were not able to go ahead at present. Repairs required to furniture and fittings in bedrooms on Gainsborough had yet to be completed, however an extended timescale had been given for this repeat requirement, and the home had until the end of May to complete this. A requirement was made in 2006 that adequate storage space must be provided. New storage areas had been built, although a large drinks machine waiting to be moved prevented the usage of one. There was still evidence of items kept inappropriately in corridors and stairwells, and also in one of the bathrooms. The deputy manager advised that two bathrooms were currently not in use. There are five bathrooms for the twenty-nine residents on Gainsborough, one of which was not in use. There are four bathrooms on Constable, for thirtyseven residents, one downstairs and three upstairs. One of these was not in use. Hot water outlets had been maintained at or around 43 degrees Celsius. At the random inspection undertaken on 23rd March 2007, a bar of soap was seen in one of the bathrooms on Constable Unit, increasing the risks of cross infection if shared. All bathrooms were inspected on this occasion and there was no evidence of bars of soap left in bathrooms. In the course of the inspection a cleaning trolley was found temporarily stored in a bathroom, the mop was head down in the bucket on the trolley. This was discussed with a cleaner and with the deputy manager, and the inspector asked to see the general area where mops were stored. These were seen to be in a locked unit, and mops there were also stored head down and damp. The mops were carefully colour coded for each unit and for different areas within the units, but the storage was not conducive to good infection control. A relative had contacted CSCI in the week of the random inspection to state that they had visited and found their parent’s room smelt strongly of urine. The visit had occurred just after midday. At the random inspection, the acting manager advised that one relative had spoken to them, about a localised odour. They advised that they had explained that the laundry for this resident had to be taken down stairs after the main laundry, as an infection control measure, and that it could not be helped if there was a localised odour until this was removed. A recommendation at the unannounced inspection that where there is a delay in removing laundry from a resident’s room, the bag should be tied once filled to prevent odour contaminating the room. No evidence of laundry bags waiting collection was seen at this inspection; a staff member confirmed staff had been instructed to tie laundry bags after they are filled, rather than waiting to tie it before it is moved to the laundry. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 20 The home’s notice on the use of hand gel between attending to residents had been amended to clearly state that this is a supplement, not a replacement for hand washing. Catchpole Court Residential And Nursing Home DS0000024351.V341291.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 receive care from a well-trained staff group, who have been properly recruited. EVIDENCE: A requirement was made at the last key inspection that staffing levels must be maintained so that call bells can be answered promptly and residents with dementia are not left for periods unattended. At the random inspection, a senior carer spoken with advised that the number of care staff on the early shift on Constable had been increased by one. This was supported by the written details of staff on duty that day provided. The home was fully staffed on that day. Time was also spent on Gainsborough, and some staff presence was constant in the communal areas through out the inspection. At this inspection a carer advised that there had been six on shift plus the breakfast helper, but said that the work was still heavy, as lots of residents require assistance with feeding. During the day staff were observed feeding residents in a calm unhurried way, and there was no evidence that call bells were left ringing for long periods. Time was spent on Gainsborough, and again there was staff presence in the communal areas during the afternoon. At the random inspection, two residents spoken with both commented that the breakfast assistant, who had been at the home for a number of years, was Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 22 very caring. The resident who was bedridden advised that this worker does regularly look in their room and have a brief word with them, and will appropriately say if asked to do a task not within their scope that they cannot, but will get assistance. Again, at this inspection they confirmed that they valued this workers input into their care. The deputy manager advised that the home was currently short of six full time carers, but had just recruited a qualified nurse from overseas who had very good English. Seventy-eight hours were scheduled to be covered by agency carers in the following week. This is a significant reduction in the level of agency work required six months previously. A nurse spoken with confirmed that the use of agency staff was reducing. Recruitment records of two members of staff who had been employed this year were inspected. They both had all of the required information and checks. In one case the contract start date was prior to the references and PoVA First check coming through, however, the rotas show that they did not start on shift until this was received, and that they were then supervised. Both had induction training evidenced. Criminal Records Bureau checks were seen to be in place for all staff. A carer spoken with advised that all of their training was up to date. A requirement was made at the last key inspection that the Registered Persons must provide adequate training in dementia for all staff working on Gainsborough unit, and provide evidence of this. At the random inspection it was evidenced that eleven staff were booked onto the dementia distancelearning course at a local college. Confirmatory emails of these training bookings for twenty-six staff to attend an in-house training day on Dementia between the 2nd and 3rd of April were also seen. A requirement was made at the last key inspection that the Registered Persons must provide evidence of staff training on the use of physical interventions and de-escalation techniques. Evidence was seen of three one-day courses for twenty twenty-two staff who work on Gainsborough. This had been organised by the Craegmoor Training officer. A training schedule for all staff was provided. This included refresher training in moving and handling, control of hazardous substances, fire safety and handling violence and aggression on an annual basis; safeguarding, the Protection of Vulnerable Adults every two years, and food hygiene three yearly. Catchpole Court Residential And Nursing Home DS0000024351.V341291.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): 31,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect there to be a wide range of management checks in place to support and improve the quality of the care they receive, and keep safe the environment in which they live; they cannot however be assured that all risks to their health and safety will be minimised. EVIDENCE: Catchpole Court has been without a registered manager since August 2004 and since this time there have been three acting managers. A requirement was made at the last key inspection and subsequent random inspection that a registered manager application must be submitted. The current acting manager, who had been in post since December 2006, advised in March that they had decided to put in an application to become registered Manager. They Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 24 attended the CSCI in March but on that occasion had not obtained the correct CRB form, and no complete application had been received by 18th April 2007. As detailed under the complaints section of this report, the home’s regulation 26 reports had been undertaken and the all items required by regulation had been covered in the last two reports. The results of the most resident survey were seen at the random inspection. Regular resident and relatives meetings had been set up. Minutes of a residents meeting held on March 11th were seen, at the random inspection, and a further date had been organised and advertised. Evidence of interest paid into an account held by the company on behalf of residents had been provided prior to the inspection, as had been required. Audited accounts which showed the home to be financially viable were provided to the CSCI prior to this inspection. At the random inspection the home evidenced that supervision sessions with staff had begun, with each member of staff starting afresh with new records of supervision. They were planning to programme four sessions for each person this year. They understood that this was less than the recommended frequency but this was all that could be reasonably accomplished this year. The content of the records seen varied significantly depending on the supervisor. On this occasion one carer spoken with said that they had not had supervision since last year. A record of supervisions held was provided which showed that a number of staff had had no supervision since December 2006. A number of health and safety requirements were identified at the random inspection. These were found to have all been attended to, with the exception of inappropriate storage of a number of items, including boxed papers, a chair and cardigan, and a special mattress in halls corridors and stairwells. Some of these items were removed on the day of the inspection when they were brought to the attention of the deputy manager, however corridors and stairwells should not be used for storage. A requirement was made at the unannounced inspection that floor cleaning fluid should not be accessible to residents with dementia. On this occasion both of the sluice cupboards including the cupboard where these materials were stored were found to be locked, however, the cleaning trolley with various products on it was found to be stored in a bathroom that was not in use, but which was accessible. A cleaner and the deputy manager were spoken with about this. The cleaner advised that if they were called to do another task then rather than take the trolley to lock in the sluice cupboard they might store it in the unused bathroom, as they felt it unlikely any residents would go in there. The deputy manager understood and reiterated that although it might Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 25 not be likely; if it did happen and the fluids were drank or spilt there could be very serious consequences. They asked the cleaner to move the trolley immediately to one of the locked storage rooms. Doors to walk in cupboards containing hot water tanks and unlagged hot piping were both found to be locked. A linen cupboard with a door marked fire door keep locked which was not locked on the day of the random inspection undertaken in March, was found to be locked on this occasion. A walk in gas cupboard marked fire door keep locked was found to be unlocked. This was discussed with the handy man and the deputy manager. It was established that the meter reader had called two days prior to the inspection and had not locked the door after them when they returned the key to the office. The handy man advised that they did a check of all doors on a daily basis, but since this door was “always locked” it had not been in their schedule. The door was locked once this issue was identified. At the unannounced inspection, the hot water temperature at one bath was found to be 50 degrees Celsius, and the hand basin in the same room was 54 degrees. When this was seen again in the presence of the acting manager, the bath was recorded at 50 degrees Celsius and the hot water at the sink, which was allowed to run, went up to 58 degrees Celsius. A copy of the temperature log kept was provided. This showed that when the bath was last used the immersion temperature was recorded at 38 degrees Celsius on the 19th March 2007. The manager advised that weekly checks are made on all of the bathrooms, by the handy man and that these were last done on he 19th March 2007. Records of regular checks by the handyman had been seen at the previous inspection. Immediately after the inspection the manager wrote to advise that this had been corrected and the valve had been found to be stuck, and daily testing has been put in place. The response was queried, as two outlets in the same bathroom had been excessively hot. The manager advised that both valves had been stuck, and that on the 19th March a different outlet had needed adjustment. They advised further, that some pipe work had been replaced recently in the loft and was found to be full of lime scale. On the basis that this might be the reason for the problems, they have now asked for a full survey of all of the pipe work. The home was subsequently required to provide the CSCI with records of weekly monitoring of hot water outlets. These were provided and on the occasion of this key inspection hot water at a number of outlets tested was found to be at acceptable temperatures. At the random inspection it was found that devices to hold bedrooms doors open until the fire alarm sounded were fitted to some doors, but had been removed from others. On the day of the inspection the door to the manager’s office and the door to the general officer were wide open, and stayed in this position without any prop, having no automatic closures. Although there were office staff in the close vicinity throughout the day, these doors are on a main fire exit route. This was brought to the attention of the deputy manager, who Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 26 advised that they did not think they were required. The deputy manager reported back to the CSCI immediately following the inspection that they had liaised with the fire officer who studied the fire plans and instructed the home via e-mail that owing to these doors opening onto a corridor, door closures are needed. The deputy manager advised that they would ensure these were fitted as soon as possible and will inform CSCI once completed. At the unannounced inspection, a wooden cupboard on the first floor level stairway was seen to have been removed in compliance with the fire officer’s requirements. On that occasion there were two workmen were present in the home who were undertaking work to support the fire officer’s requirements, including replacing glass in all fire doors with safety glass, and putting smoke seals and intumescent strips on fire doors. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 27 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 3 X 2 3 2 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 2 X 3 3 3 1 3 2 Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 28 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. 2. Standard OP3 OP9 Regulation 14(1) 13(2) Requirement Pre Admission assessments must include primary need and any dementia diagnosis. Staff administering medication must follow the good practice guidelines of the Royal Pharmaceutical Society and not handle medication as this practice can contaminate and affect medication. Redecoration and refurbishment of Constable unit is required to provide an environment of acceptable quality for residents to maintain their dignity. Repairs must be made to furniture and fittings in bedrooms on Gainsborough, as the damaged surfaces of some are an infection control hazard. This is requirement, which was within the timescale set at the random inspection. Mops must be stored in accordance with good infection control procedures to reduce the risk of spreading infection. A registered Manager application must be submitted. This is a DS0000024351.V341291.R01.S.doc Timescale for action 07/07/07 07/07/07 3. OP19 23(2) 30/09/07 4. OP24 16(2)(c) 31/05/07 5. OP26 13(4) 18/05/07 6. OP31 CS Act 2000 Sec 31/07/07 Catchpole Court Residential And Nursing Home Version 5.2 Page 29 11 7. OP36 18(2) 8. OP38 13(4) repeat requirement from the inspection of 26th January 2007. Formal supervision must take place in line with the home’s policy, and sufficiently regularly to support and monitor staff. The doors to the manager’s office and nurse’s office must be kept closed unless they are on automatic closures linked to the fire alarm system. 31/07/07 18/05/07 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 OP19 OP10 OP24 OP21 OP38 Good Practice Recommendations The environment for residents with dementia should be developed to better meet their needs, with identifying features on individual rooms, and additional sensory stimulation. The bathrooms that are not currently used should be reopened for use. The walk in gas cupboard that must be kept locked should be regularly monitored. 2. 3. Catchpole Court Residential And Nursing Home DS0000024351.V341291.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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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