Inspection on 02/08/05 for Catchpole Court Residential And Nursing Home

This inspection was carried out on 2nd August 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... 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 Walnut Tree Lane Sudbury Suffolk CO10 6BD Lead Inspector Mary Jeffries Announced 2 August 2005 nd 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 I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Catchpole Court 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 I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13/04/05 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 I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on one day and early evening in August 2005, and the inspector was present for nine 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 seven months. Sixty Six service users were in residence on the day of the inspection: there were two vacancies on Constable. 10 relatives provided pre – inspection comments cards. Four gentleman and two ladies were spoken with in group situations on Constable Unit. One service user on the DE Unit and one on the frail elderly unit were spoken with individually in their rooms. Two pairs of relatives who were visiting service users with dementia were spoken with. Care, nursing, and domestic staff also assisted with the inspection. What the service does well: What has improved since the last inspection? What they could do better: Any restrictions on service users as described in the care plans must have been consulted with relatives and GP’s where appropriate, and this must be evidenced. Documentation on the administration of medicines must be improved to clearly demonstrate any changes in medication. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 6 Care and management of the environment needs to be improved, including the storage of all hazardous substances. There was a shortfall in staff training in terms of National Vocational Certificates and specialist dementia training. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4, 6 Service users who are funded by the local authority can expect the home to have obtained a single joint assessment prior to their admission. They will also be assessed by the home, as prospective privately funded service users will be prior to admission. This assessment will be comprehensive. Service users entering the dementia unit cannot expect all care staff to have had specialist training. EVIDENCE: Appropriate pre-admission assessments had been completed prior to admission of service users; contracts were issued after the trial period of one month with signed copies being kept on file. It was noted that the room number on one of the contracts seen was not the number of the room occupied by the service user. Service users who were funded by Social Care Services had community care joint assessments on file. They also had the home’s own assessment which was comprehensive, and included an assessment of whether the service user Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 9 could manage the nurse call bell, and Waterlow pressure area assessments as well as falls risk assessments, manual handling assessments and nutritional assessments. The assessment documentation for a privately funded Service user who did not have a Social Care Services joint assessment, and who had been admitted 3 days prior to the inspection, was seen to have been completed prior to admission. An outstanding requirement for dementia training was in place. Details of a dementia training course were seen. The Acting Manager advised that this has been arranged to take place within the agreed timescale, but no supporting documentation was available to confirm this. The Acting Manager confirmed that the home did not provide intermediate care. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 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, 9, Service users can expect to have a comprehensive care plan, based on their assessment, which covers all areas of need thoroughly. Medication recording practices at the time of the inspection were not acceptable. EVIDENCE: At the time of the inspection the home was investigating a complaint from a relative regarding the loss of medication brought into the home for a Service user on a short stay. Medication administration was observed in Constable Unit, and records were checked for these service users and 4 service users on Gainsborough unit. The records were for a five day period. All records seen had photographs of service users. One gap was noted. Medical administration Records (MARs) sheets did not clearly reflect changes in medication required. On a number of records, medications had a note to state, “non delivered this month”, and had not been given, but the sheet did not indicate that the prescription had been stopped. On one record, there was a note to state, non delivered this month, and yet had been given. The home Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 11 advised CSCI immediately following the inspection that they had dealt with both requirements arising from these, and that in addition to correcting errors found, interviews with staff responsible for the administration of medicine have been booked. The inspector observed a nurse take an insulin “pen” into the dining/sitting room, and the nurse confirmed they had administered it to a service user. The service user concerned was asked how they felt about this, and said that they did not mind. Other service users views were not sought. The inspector was advised that four service users had been screened to establish their current MRSA status. Only one of these was currently positive. Care Plans were checked and this was detailed in the individual plans and also in written communication. The room of the service user with MRSA was seen and had the laundry bins and bodily waste bins as per the care plan policy. There was no en-suite in this room. Three service users who had bed sides in place all had assessments for these on file, but non had been signed by a relative or a G.P. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 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, 15 Service users can expect to enjoy a varied, wholesome, balanced diet. Those who require assistance with eating their meals can expect to find that this is provided sensitively and appropriately. Some aspects of the mealtime environment could be improved, and recommendations have been made. EVIDENCE: The Acting Manager advised that the need for staff to work holistically had been emphasised to staff since the last inspection, when it was noted that social interaction with service users was limited. The timescale given for this had not been reached, and it will be further assessed at a future inspection. Menus were provided by the home prior to the inspection. These were varied and nutritious. Four service users spoken with in a group at lunchtime did not know what they were having for lunch. The menu for the week was displayed on the dining room wall on Constable Unit, and a carer worker said that choices for the lunchtime meal had been discussed with the service users the previous evening. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 13 Two confirmed that food was an important part of the day for them, and agreed that they would rate the food as generally on the good side. Sixteen service users responded to the pre inspection survey which asked if they liked the food. Fifteen answered yes, one answered sometimes. There was a choice of meal for main course and pudding, and fresh green vegetables were available. The meals were served plated, however, they looked very appetising and those service users who had selected the same main course, had their meals individually tailored, for example the number of eggs, whether they had chips, whether they had vegetables. A pureed meal was served to one service user who cannot eat solids. The lunch was served in a relaxed and unhurried manner, and a carer was at each table to assist those who needed help. Some service users ate at tables pulled up to their chairs, rather than the main table, some of these were in the veranda. Some of these were also assisted with their midday meal, and assistance given was seen to be discrete, sensitive and appropriate. Staff and service users confirmed that they always had a roast lunch on Sundays, followed by a buffet tea. A bowl of bananas was available in the lounge/dining room for service users to have between meals. There were two large plastic swing top bins in the dining room/ sitting room through out the lunch time, for dining laundry. This is not a normal domestic arrangement, and it is recommended that these are not kept in this room, or are exchanged for bins that are more in keeping with dining room/living room furniture. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 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 The home had formal systems to respond to complaints that service users and relatives spoken to thought they were effective. EVIDENCE: The complaints policy displayed had no timescale within it. The home had a well-maintained complaints log, which included concerns and complaints, including those that had been anonymous and received through the box outside of the Acting Manager’s office. Two complaints were logged for May, 4 for June and 4 for July. A number of outstanding complaints were being dealt with by the home at the time of the inspection. Service users and relatives spoken to at the inspection reported that they felt that they could raise complaints, and something would be done: two relatives gave examples of this happening, as did a service user. A minor issue a service user advised they had reported to carers regarding missing clothing was not known to the manager. Two minor shortfalls in employment practices around Criminal Record Bureau checks were found. These are detailed under the section 29 on employment. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 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, 24, 25, 26 The home did not appear to be well kept. Some service users may find the standard of cleanliness, decoration and attendance to minor repairs unacceptable. There continued to be a lingering odour in many parts of the home. Service users can expect to be able to personalise their rooms, and that they will be safe and comfortable. Storage of equipment in bathrooms and the dining room sitting room detract from the homeliness of the environment. EVIDENCE: Much of the decoration in the home was tired, some doors scuffed and paintwork chipped, and also the cleaning appearing not to be of a high standard. The main kitchen was inspected and found to be very clean. In a satellite kitchen, there was a refrigerator, and the icebox had a brown frozen mass in it. The inspector was advised that this was probably something Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 16 staff had brought in. A cobweb was seen hanging from a ceiling in one of the bathrooms in Constable. A number of the W.C’s throughout the home had brown staining in the bottom of the bowls. A dirty incontinence pad was on the floor in one bathroom. In one small kitchen, the floor underneath a small sink was marked. This was discussed with the domestic staff who advised that this was due to staining. In this kitchen, the small hand sink was not very clean, and the tops of electrical sockets were slightly dusty and grimy. High cleaning was checked in a number of areas and found to be acceptable. The Acting Manger advised that since the last inspection the maintenance person is no longer at the home, and a maintenance worker from another of the groups homes was working two days a week. A schedule of refurbishment to rooms was provided, and also a weekly and monthly maintenance schedule. Two service users’ rooms that were previously double, and are now for single occupancy were checked and found to have had rails for screens removed. Individual rooms seen were personalised, and safe. Suitable lockable storage facilities were seen to have been provided in a number of rooms inspected. In one service user’s room, relatives pointed out that the radiator cover had fixing was broken on one side. The service user was not ambulant and this did not pose a risk to them. It was not included on the room refurbishment list. A bathroom on Constable unit was found to be cluttered and untidy, and had 2 laundry baskets stored in it. The light in one service user’s en-suite room was found not to be working. Check internal lights was on the weekly maintenance list. Some, but not all service users’ rooms had photographs of the Service user on them. The garden for Gainsborough, the dementia care unit, had tufts of grass growing between the path paving stones that represented a tripping hazard. This was not on the maintenance schedule. The hairdressing room was found to be unlocked, and within it was a jar of fluid to disinfect combs. The washing up room was found to be unlocked, and had a bottle of cleaning fluid in it. Emollient was in an unlocked bathroom cupboard on the Dementia Unit. This was discussed with the Assistant Manager, who advised that all non prescribed creams are usually kept in service user’s rooms. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 17 One of ten service users’ relatives who responded to the pre – inspection survey commented “some parts of the home rather smelly.” Unpleasant odours were apparent in a number of places across the home. At the time of the inspection the home was dealing with a complaint from a relative concerning, in part, the cleanliness of the home. 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. At the last inspection this had not been done and a revised timescale was given, until 30th September 2005. One of these carpets had been cleaned again, but marks remained. The other had not yet been replaced, but a quote had been obtained for it’s replacement. The CSCI have required that an action plan be submitted in respect of how sufficient natural light is to be provided within rooms 25, 26 and 27. This is a repeat requirement, within a revised timescale. Three rooms were seen to be dark without electric light as a result of trees in close proximity. A relative spoken to stated that they had complained about the darkness of a room that their relative had been in when first admitted to the home, and the service user had been moved. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 18 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, 30 The staffing levels on the day of the inspection were at an acceptable minimum level for the number of service users in the home. Lower levels of staff employment as apparent on the rotas provided would stretch resources. Until the recently recruited staff are in post service users may find staffing levels less than good at times. There is a need to develop staff training in NVQs and dementia care. EVIDENCE: The staffing level on Constable during the morning was 1 staff nurse and 5 care assistants. In the afternoon it was 1 staff nurse and 4 care assistants. The staffing level on Gainsborough during the morning was 2 staff nurses and 7 care assistants. In the afternoon it was 1 staff nurse and 7 care assistants. In addition to this there was a breakfast assistant. Care staff spoken to were of the opinion that there were sufficient staff on the day of the inspection. They stated that if someone was off sick, or if there was a particular problem to deal with during the day, they could be very pushed. There are 37 beds on Gainsborough unit. The staffing rota showed that in addition to the two nurses, 4 care staff were on duty on Gainsborough during the morning of the previous weekend. It showed 3 cares to be on duty on the previous Saturday afternoon, and on two afternoons during the previous week. This is equivalent to a level agreed for evenings for up to 33 service users when staffing agreements were in place. The staffing rota for Constable for the previous week showed acceptable staffing levels. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 19 At the last inspection a requirement had been made that the home must employ an appropriate number of staff with an appropriate skill mix to meet service users’ needs consistently, as a large number of agency staff had been used, by the end of September 2005. A number of new staff had been recruited, and were due to commence work once all appropriate checks had been received. Staffing seen in the day, discussed with the manager and evidenced on the rota showed that only one shift was being covered by an agency worker on the day. A recommendation had also been made at the last inspection that a review of 6 and 12-hour shift patterns should be completed and any findings implemented. The Acting Manager advised that they had reviewed working patterns, but that a number of staff had indicated that they preferred double shifts, and that they had not been in a position to change this. However, they advised that changes had been made to reduce the number of staff working two long days in a row. Care staff spoken with advised that two carers only, now had this shift pattern. The Pre-Inspection questionnaire stated that the home, in total employed 12 registered nurses and 32 care staff. It stated that only 8 of the care staff had NVQ 2 or above. A schedule of training statistics provided on the day of the inspection confirms this. This is only 25 of care staff employed. The training schedule shows that a further 3 carers are undertaking an NVQ. Three quarters of care staff had received manual handling training, or alternatively achieved an NVQ, according to the training schedule provided. On going Manual Handling training had been arranged. The staff files of the last 4 care workers recruited were inspected. There was no Criminal Record Bureau check on file for a newly employed carer. The Acting Manger advised that employment files were kept at head office until all required details, including details not listed under Regulation 10 schedule 2, but relevant to personnel were available, and were then sent to the home. Also, that the home does not start care staff working without head office has notified them that CRB check has been obtained, unless a PoVA First Check had been undertaken. In that case, the Acting Manager advised, close supervision arrangements were out in place. Other employment files inspected demonstrated the system of staff records, and a CRB number was available for the member of staff where this was not on file. This practice does not meet the regulations. Another worker did not yet have a CRB, but did have a PoVA first file that had been done immediately prior to them taking up their post. The manager advised that supervision arrangements had been put in place for this worker, but was not able to provide a signed undertaking of the responsibility being undertaken by this member of staff as detailed in the amended regulations. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 20 Service users spoken with had no complaints about staff, two mentioned how helpful their key workers were. One service user said that communication had been a bit difficult with one worker from abroad, but that they had got over this. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33,35, 36,38 A number of requirements have resulted from the owning company’s practices at a higher level not complying with the standards, for example recruitment and surveying work. Systematic and regular monitoring of key practices such as cleaning, maintenance, medication, health and safety is required. The annual Service user Questionnaire due to be carried out in August will provide the Acting Manager with an opportunity to ensure that the home is being run in the best interests of Service users. Supervision of staff was not at an acceptable level. A number of health and safety shortfalls were identified. EVIDENCE: An application to Register the current manager had not yet been received. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 22 A requirement of the previous inspection was that staff supervision must be put on line by September 2005. The manager stated that little progress had been made on this, as the owners have introduced a new system of supervision that they are required to put in place by the end of August. A carer spoken with advised that they had only received one supervision since they had started work at the home. A Craigmore Homes control of infection policy was in place. The home also had the West Suffolk Health control of infection policy available, which contained local procedures. A contract for the removal of clinical waste was seen to be in place. A carer spoken to was able to describe the special precautions for service users with MRSA, and for all service users. Protective clothing was seen to available at a number of places throughout the home. The fire logbook showed two fire drills had taken place since the last inspection. All service users’ rooms were seen to have been fitted with door guards. A door to the washing up area, marked fire door, did not have a door guard and was propped open. A door to a storeroom below a stair well was marked “ fire door, keep locked”, but was found to be unlocked. The Acting Manager advised that this had to be kept closed, not locked. It was not possible to check this against the fire risk assessment. There was no fire risk assessment available in the home, although the Acting Manager advised that one had taken place and the home was awaiting receipt of this. In another part of the home, a notice stated, “This Door must be kept locked for the safety of residents”. It was not locked, and the Acting Manager advised that this sign was no longer relevant, as it was next to a door that used to be an entrance that was no longer used. Signs must in place must be correct and followed. A box for anonymous comments, concerns etc was in situ outside of the manager’s office. The inspector was advised that a survey of service users views had not been undertaken so far this year, however, it is normally undertaken annually in August. Some service users’ monies, pocket monies only, are held in the home. Records were checked for 7 service users. Of these, amounts tallied with amounts kept and receipts were available. The acting manager stated that no staff members who worked at the home acted as official receivers for any of the service users in respect of their finances. This was done by service users themselves, their families or appointed powers of attorney. A list of possessions brought into the home was on the service users’ files checked. These were not signed, and they did not include valuable such as rings or watches services users might have been wearing. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 23 The Acting Manager had a short list of items that had been found, and that they did not know who they belonged to. One relative responded to the pre inspection survey with a statement that too many things were missing from their relative’s room. They were contacted and advised that a Mackintosh, a watch and a ring were currently missing. The relative who was concerned about a missing ring confirmed that they had been asked to come and see these items to try to identify if these included this item. One service user spoken with advised that two reasonably expensive clothing items had been missing from the laundry service for at least two months. They said that they had informed carers, but had not complained, and did feel they would be able to do this. Regulation 26 reports had been regularly received by the CSCI. Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 2 2 STAFFING Standard No Score 27 x 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 2 x 2 2 x 2 x 3 2 x 2 Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 25 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. 2. Standard 2 4 Regulation 5(1)(b) 10(1) & 18 Requirement Service users contracts should correctly specify the room occupied. The staff team working at Gainsborough House must undertake specific training in working with people with dementia.This repeat requirement was within timescale. The requirements of the service users for whom medication has not been continued must be established and met. Any restrictions on service users should be detailed and signed for by appropriate representatives on the care plan. Medical Administation Records sheets must clearly show any changes in medication. Emollient creams should not be kept in comunal bathrooms. The complaints policy must include a timescale within it. 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. This Timescale for action 30/10/05 31/12/05 3. 9 13(3) 14(2) & 17(3)(a) 13(7), 15(c ) 13(3), 14(2) 13(3) 22(2) 23(2) (b,d) Immediate 4. 7 Immediate and ongoing Immediate Immediate and ongoing Immediate 31/09/05 5. 6. 7. 8. 9 9, 38 16 19 Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 26 9. 19 23(2) (b,d) 10. 11. 12. 19 21 25 23(2)(o) 23(2)(n) 23(2)(p) 13. 26 16(2)(k) 14. 15. 26 26 23(2)(d), 13(4)(c), 16(2)(j) 12(1)(a), 13(4) (a)(c) 13(4) repeat requirement is within a revised timescale. The carpet on and around the stairwell on Constable House must be replaced. This repeat requirement was within a revised timescale. Pathways in the gardens must be kept free of vegetation. Bathrooms should be kept tidy and uncluttered. 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 repeat requirement is within timescale. The home must be kept free from unpleasant odours. This requirement is repeated from the last seven inspections. Cleaning standards must be improved. There must be liquid soap and paper towels in all communal wc’s and bathrooms, and in the sluice facility, to avoid the risk of cross infection. Hazardous products must be stored in the locked COSHH cupboard when not in use. This should include non prescribed medicines and toiletries on the Dementia Unit. Criminal Rcord Bureau checks must be on file at the home until they have been evidenced by the CSCI. Staff without a CRB check, but for whom a PoVA first check has been obtained , must have a supervision plan in line with the regulation. A strategy is required to achieve 50 of careres with NVQ2. An application must be made for 31/09/05 31/08/05 Immediate 31/08/05 31/08/05 Immediate Immediate 16. 26,38 Immediate and ongoing 17. 29 19, 2(b) Immediate 18. 29, 18 19(9) Immediate 19. 20. 30 31 18(1) Care 30/09/05 31/08/05 Page 27 Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 21. 36 22. 23. 24. 38 38 Standards the homes Manager to be Act 2000 Registered. This repeat Section 11 requirement is within timescale. 17(2) All staff must receive ongoing Schedule regular formal supervision.This 4(6)(f) & repeat requirement was within 18(2) timescale. 23(4) A fire risk assessment must be in place in the home. 23(4)(e) Fire doors must not be propped open. 31/09/05 immediate Immediate and ongoing 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 15 Good Practice Recommendations The menu for the main meal each day, rather than the weeks entire menu, should be displayed prominently so that service users can know what they are looking forward to. Large plastic swing top bins are not appropriate domestic type furnishing for a dining room / sitting room and should be replaced. Where large bins for waste and laundry that is to be isolated are in place in service users rooms, in accordance with control of infection policy, dignity and privacy of the service user should be enhanced by screening these off. Maintenance and cleaning schedules should be reveiwed. All service users rooms on the dementia unit should have photographs or identifying symbols on them. Service users should be asked if they have any views about staff working long shifts at the next service user survey. Property lists of service users valuables should include jewellery worn by the service user on admission, and should be signed. 2. 3. 15 10 4. 5. 6. 7. 8. 19 24 33 35 Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection St Vincent House Cutler Street Ipswich, Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Catchpole Court I54-I04 S24351 Catchpole Court V233905 050802 Stage 4.doc Version 1.40 Page 29 - 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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