Inspection on 26/06/06 for Catchpole Court Residential And Nursing Home

This inspection was carried out on 26th June 2006.

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

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

Other inspections for this house

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

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

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

Catchpole Court Residential And... 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 26th June 2006 10:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Catchpole Court Residential And Nursing Home DS0000024351.V297217.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.V297217.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 Speciality Care (REIT Homes) Limited Post Vacant Care Home 66 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (29) of places Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 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. The deputy manager advised that fees for the home were currently £365 pw plus any nursing fees and agreed extras. Hairdressing and chiropody are provided at an additional cost. Catchpole Court Residential And Nursing Home DS0000024351.V297217.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. Two inspectors undertook this inspection, breaking for lunch to liaise on progress. The inspection took approximately seven and a half hours, an hour was spent on feedback to the deputy manager. The inspection was facilitated by the deputy manager, who attended the home for this purpose as the manager was on sickness leave. A Pre Inspection Questionnaire was provided. This was received by the CSCI, by mail, on the day of the inspection, so there was no opportunity to discuss the contents with management of the home, therefore information provided in it is not included in this report. Two groups of service users on Constable, the frail elderly unit were spoken with. One service user was spoken to in some depth alone, and two sets of relatives were spoken with. Two of the places on Constable unit were empty, and two of the service users from this unit were in hospital. All of the places on Gainsborough unit were full. What the service does well: What has improved since the last inspection? Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 6 Standards of cleanliness in the home had improved since the last inspection, bedrooms were found to be free from odour as was the communal area on Constable. The infection control policy included use of hand gel, and staff were properly aware of its use and limitations. Décor on Gainsborough had improved, and some carpets had been replaced. The lounge/dining room on Constable was free from odour. Water jugs in this room now had proper lids on them. A complaints log had been maintained. Staff had received training in the protection of vulnerable adults. What they could do better: Full pre admission assessments must be obtained, care plans must be completed in a timely way, and practices reviewed at an appropriate level when service users’ needs indicate. Restrictions on service users must only occur in line with risk assessments which evidence consultation and are signed by appropriate representatives on the care plan. Although a programme of supervision was found to have been set up at the last inspection, regular supervision was not evidenced on staff files inspected. One service user spoke of being treated less than respectfully, and another was overheard being responded to sharply. A number of matters relating to privacy and dignity need to be addressed. Regular service user meetings should be held and their views elicited to contribute to the ongoing running of the home. Further effort needs to be put into removing odour in some communal areas, and the programme of redecoration needs to be completed. The CSCI should be notified of the progress on plans to enhance natural lighting in two service user’s rooms. Storage was careless in some places, and the environment needs to be kept free of risks to health and safety. A restriction, in the way of a keypad on the door of the frail elderly unit must be removed, and no service user should routinely have a lap belt used whilst sitting in a wheelchair, without evidence that a risk assessment indicates this is necessary. Financial transactions on behalf of service users must be witnessed by two members of staff. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 7 The dementia environment needs to be equipped to stimulate and orientate service users, with appropriate symbols on doors, sensory stimulation and picture menus. Care plans for service users with dementia should include life stories. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Catchpole Court Residential And Nursing Home DS0000024351.V297217.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.V297217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 6 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst hospital discharge data is obtained for service users who are admitted from hospital, service users may not have had a full assessment prior to being placed at the home, and therefore cannot be sure that the home can meet their needs. EVIDENCE: Contracts were seen on three files inspected. Files had hospital discharge data, including discharge health assessments, but not Social Care single assessments. This was discussed with the deputy manager who advised that a number of the service users were privately funded, and that single assessments were therefore hard to obtain. It was found that one service user without a pre-admission single assessment had subsequently had a review, which included a social worker’s contribution. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 10 The assessments on two of the care plans inspected were the homes own assessments and had not been completed prior to admission. One of the care plans inspected did not have a complete assessment or plan on it two weeks after admission – see standard 7. A couple of the service users spoken to in a group on Constable complained that they found the behaviour of one service user on their unit annoying. They described them as someone who spits things, and the service user was observed repeatedly pulling the tray of the service user they were sitting next to. This service users care plan did not state that they had a dementia diagnosis, but did note that they were confused. Another service user asked about the atmosphere on the unit replied, “ It seems alright to me.” The deputy manager confirmed that the home does not provide intermediate care. Catchpole Court Residential And Nursing Home DS0000024351.V297217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users can expect to have a comprehensive care plan, but this may not be completed in a timely way, and service users cannot be confident that a review of their case or of care practices will be triggered when necessary. Medication was generally good, and service users can expect this to be properly administered. Aspects of maintaining privacy and dignity and respectful treatment of service users need to be improved. EVIDENCE: Three care plans were fully inspected and two were inspected in relation to issues raised during the inspection. All files had care plans. Four were up to date and had been reviewed in house within the last month; two had a recent review including social care services. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 12 The care plans were generally good, current, and included hygiene and personal care, incontinence, mobility, diet, social isolation, and funeral arrangements. Funeral arrangements were completed in most cases, in one a note was made that it had not yet been possible or appropriate to raise this with relatives. Plans also included interventions required for medication and pressure areas. Record of GP visits were maintained, as were up to date falls risk assessments. There was no life story or history on the care plan of service users with dementia whose care plans were inspected, although there was a pen picture in each room, providing a synopsis of the service users care needs. One service user seen had a peg feed, and there was a risk assessment on food taken in addition to the peg feed, this had been reviewed in June, and also the falls risk assessment had been reviewed in June. A service user was spoken with, and they reported that they were very unhappy and were treated very badly. They said that carers are short with them, and sometimes handled them roughly whilst attending to their care. A male service user with dementia who had been admitted approximately three weeks prior to the inspection was in some distress, and could be heard from outside the building. One service user on Gainsborough said to the inspector that they had “had enough”, as they had such a noisy neighbour. The service user they referred to was in their bedroom, shouting and screaming. When seen they were sitting in an armchair in their room, with their eyes closed, banging the armchair. This service user was discussed with two of the carers on Gainsborough unit. They advised that the service user had only been on the unit for about two weeks, and that they knew little about them. They advised that they could not take the service user into the lounge, as the screaming upset other people. This service user’s care plan had very limited information it. The template for risk assessment of challenging behaviour was not completed, nor was the template for memory and orientation. There was no behaviour management plan, and no record of G.P. visits. Several templates for assessment were not completed, for example mouth care, mood, pressure sores, moving and handling, daily living, nutrition. Accident records were inspected for these five service users, two had had one accident each recorded since the beginning of the year. Service users spoken with advised that when they wanted to see the doctor they were able to, and that this was arranged promptly. Other files inspected evidenced the attendance of other health professionals, and regular blood glucose tests where this was needed. One of the service users’ care plans had a weekly weight chart that had not been completed between 19th February 2006 and 8th May 2006, the last entry. There was also a monthly weight chart on file, which gave weights for May and Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 13 June 2006. There was a 4.6k drop in weight between these two records, which was a significant drop for the size of the service user, who was 79k at the previous weighing, but no indication that weekly weighing had recommenced. The action plan received following the previous inspection advised that recliner chairs had been ordered, and no lap belts were in current use, with the exception of a one wheelchair user, where a risk assessment was provided, and this was appropriate. Additionally a centralised book on each unit had been started to record all restraint if/when used. Another service user was sitting in a wheel chair and wearing a seat belt on the day of the inspection. This was during the morning. The deputy manager advised that they might be waiting to be transferred, as they do not keep service users sitting in wheel chairs. The service user was seen later in the day with a lap belt on in a wheel chair at the dining table. This was discussed with the deputy manager who advised that they had misunderstood the requirements made at the previous inspection, and had thought that lap belts had to be worn if the service user remained in their wheel chair to eat. The care plan of this service user noted, “ensure lap belt is in use whilst transported in wheelchair”, and “if wheelchair needs to be used at the table, this must be documented.” A service user, whose care plan states has a dementing illness, had bedsides in use; these were noted on the care plan but there was not a signed risk assessment on the plan. The administration of medicine was observed on Gainsborough unit. The administration was undertaken by a nurse. A blister pack system was used, with additional medications stored in bottles etc. Medications were given and then signed for, and the nurse locked the medicine cabinet every time it was left. Boxed medicines were found to be dated and signed when opened. One strip of calcium tablets, however, were found to be loose in the cabinet. There was no service user’s name on them, and they were not in their original packaging. A service user on Gainsborough who had been at the home for about two months, and their relative were spoken with. The relative said that their parent had settled well and that the girls were very kind and patient. One of the group of service users spoken with advised that they liked “the girls”, and when asked if they were confident in the care they gave replied, “I think I am confident, actually.” However, during the day, a service user with dementia seated in the dining room was overheard to ask a carer to take them to the toilet. The carer responded in a raised voice, telling them to be patient. Incontinence pads were stored discreetly in individual bedrooms, however, as the inspectors entered the building, a carer walked into the house from the garden with a used incontinence pad in their hand. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 14 A shared room seen had a privacy curtain between the beds; in another shared room (28) the beds had obviously been moved, making the privacy curtain ineffectual. There was observation glass in one bedroom door, and therefore the privacy of the occupant was not assured. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can generally expect to be able to exercise choice in their daily lives, although some inappropriate restrictions may be in place. Service users can expect to be very satisfied with the food provided to them. EVIDENCE: The home had held a fete the day prior to the inspection and a number of service users spoken to in a group commented that it had been a good day, and that they had participated in various ways. Service users spoken with confirmed visitors were welcome, one advised that “ my kids can come in when they want to.” A member of staff advised that the home has talking books and audiocassettes for a service user who cannot read. A general communion service is held each week, and a service user who is Roman Catholic is visited by that church for communion. A programme of monthly outings throughout the summer months was advertised on a notice board. These included trips to Clacton, Abbey Gardens, and Banham Zoo. A daily programme of activities for both units was Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 16 advertised, which included active for life exercises, pat dog, arts and crafts, and reminiscence therapy. The breakfast assistant on Constable unit initiated a sing-a-long, which some service users enjoyed joining in with. One service user said, “they look after us well, we have a dance, a woman comes over and we have a sing song, and if it’s someone’s birthday they make it nice.” Service users spoken with said that they had a bath about once a week, and that if the home was short of staff this might happen in the afternoon. Another said that if they were short staffed they might be asked if they minded having breakfast in bed. There was a keypad lock at the entrance/exit of Constable, the frail elderly unit. This was an unnecessary restriction on the freedom of movement on the occupants of this unit who had no mental health needs. When the group of service users were asked if they could choose what time they retired to bed, one advised, “I think so, I don’t always go. I doze in my chair.” This service user advised that they liked to do this, and that staff couldn’t make them go to bed. One of the group said that they always got up at 7 am, and came out to get their morning drink; another said that they had their cup of coffee in bed each morning. A service user in the other group spoken with said that they could have a lie-in; they could get up when they liked. The breakfast assistant on Constable advised that they did breakfast, and that a number of choices, including bacon and eggs, were available. Fresh fruit was available in a bowl on Constable unit. Service users advised that they had a hot drink and a biscuit in the evening and they could have as much as they wanted. One service user was heard to call out “ I want orange”, and an orange drink was brought to them. The daily menu was displayed on a white board in the main lounge diner on Gainsborough unit and in a dining room on Constable. On the day of the inspection service users had a choice of lambs liver or fish for their main meal. Service users spoken with were all satisfied with the food, and some were very satisfied. When asked to rate it, one gave it 10 out of 5! another 4/5. Another said, “ The foods good, without a doubt, it is.” A service user advised that they choose what they wanted the day before, and had no complaints. Staff on Gainsborough were asked how service users with dementia select their meals. They advised that some can read the choices and select, the preferences of some others are known, and the constitution of the food also guides staff in making a selection for some service users who cannot do this themselves, for example if something is harder to chew it will not be appropriate for all. They advised that if a service user does not eat the meal provided, they will always try them with the alternative, to see if this stimulates an appetite. Picture menus were discussed with staff. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 17 Some service users were observed to eat at table, other eat at their individual chairs which had swing across trays. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect staff and management to respond appropriately to protect them from abuse. EVIDENCE: Correspondence received from the Responsible Person in March 2006, confirmed actions that had been taken by the home in respect of two complaints made to the home in 2005, both of which had a number of elements, as described in the previous inspection report. No complaints had been received by the CSCI since the last inspection. The home maintained a log of complaints and compliments. One service user spoken with who was unhappy said they did not have a copy of the home’s complaints procedure. The action plan sent following the previous inspection by the responsible person stated that the acting manager would be undertaking PoVA training on 22nd March 2006, and that all staff were on a rolling programme to receive this. The homes rolling programme of training for the next six months was seen, and this contained PoVA training. The training analysis provided indicated that 18 carers, the hobby therapist and the manager had received Protection of Vulnerable adults training. Eleven of these were carers who did Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 19 not have NVQ, so although not all, a high proportion of staff had had PoVA training. On the day of the inspection, one resident made an allegation of physical assault. The nurse on the unit provided a written account to the deputy manager within a short period of time, and the manager responded immediately and appropriately. A Protection of Vulnerable adults referral was made to Social Care Service, and the staff member was contacted and advised not to attend the home for duty until the matter had been investigated. There were Criminal Records bureau checks on file for all staff tracked. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users can expect to find the home undergoing a schedule of redecoration, and that some areas are in a better state of décor than others. They can expect their individual rooms to be well decorated and comfortable, although some furniture may need repair. Service users may find that there are some localised odours in the home. Service users are exposed to a number of health and safety risks in the home. EVIDENCE: Paving stones had been power washed and were in good order. The home had reported that no damaged paving stones were found when this exercise was completed. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 21 A requirement had been made at the last inspection that the communal dining/lounge area on Constable must not also be used as an office. The responsible person had responded by advising that it was not, but that care staff were encouraged to complete tasks and records with service users to ensure involvement and close proximity should assistance be required. The notice boards in this area were tidier that had been found previously, and jugs of water below one notice board had proper lids on them. Service users sitting in this room each had a table/tray by their chair. The sitting / dining room area on Constable was free from unpleasant odour. A large fish tank was an attractive feature in this room. There were St George Flags up for decoration. The temperature in the adjacent extension was 24 degrees Celsius, and there was a fan available. The corridors and rooms on Gainsborough unit had been recently decorated, and new carpets provided in the corridor. There were only a few rooms on special needs which had identifying symbols or photos. The room of the service user who was disturbed was very pleasant. Another room seen had been made very attractive by the service user’s relative, with mobiles and ornaments. Some other rooms required attention. It was noted that in several bedrooms laminate strips were missing from vanity units (which included washbasins) thus exposing porous surfaces that could harbour bacteria and impede good hygiene control practices. There was a split edge to a door in room 34 exposing a rough surface thus constituting a health and safety hazard. Several beds were identified as being damaged, uncomfortable and in a state of disrepair. The deputy manager advised that the home had recently purchased some new beds. Service users spoken with on Constable advised that they could lock their rooms. One said, “I’ve got a key, but I don’t use it.” A window restrictor on the first floor had been repaired since the last inspection, however, another window restrictor was found to be broken. Towels were stored in communal bathrooms. The action plan provided by the Responsible Person following the last inspection advised that towels had been removed, and the situation would be monitored. A toilet on Gainsborough (6) was in the process of being redecorated. This room was accessible to service users, and contained a stepladder and other materials on the floor, which included a box of screws. Another toilet, (2), contained a broken armchair, a broken toilet and a long piece of wood with a nail in it, and had a sign saying “do not use” on the door, but was again accessible to service users. Both of these rooms constituted a health and safety risk to service users and staff. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 22 Bathroom 3 was untidy and was being used as a storage area, with towels, laundry, a wheelchair footrest and linen baskets in it. At the last inspection, a requirement was made that bathrooms should be kept available for use and not used as storage facilities. The provider responded by advising that the bathroom identified was not in current use, and the area would be reassessed for its future purpose. There was a pile of bedding in a corner in one of the corridors. On the day of the inspection the bathroom was still being used for storage. The deputy manager advised that the home was short of storage space. This was noted on the regulation 26 report sent to the CSCI in June 2006. The deputy advised that they did not use all of the bathrooms in the home. Bathroom 4 had a high assisted bath, and a bathroom on the ground floor in Gainsborough had an assisted bath. At the bottom of the stairs on Gainsborough there was a broken chair, the arm was detached and left on the chair. Following the last inspection the responsible person had advised that artificial light would be improved in the two dark bedrooms, and that they were in contact with the District Council about the trees, and that CSCI would be copied into all correspondence. No copy correspondence had been received. The assistant manager advised that it had been proposed that the council could prune the trees in such a way as to increase the light. Hygiene and cleanliness standards were generally good throughout the home, although there were faint odours in communal areas, including the lounge on Gainsborough. The lounge/dining room area on Constable was free from odour. The deputy manager advised that they believed cleanliness had improved, but that there was “still some way to go.” A requirement was made at the last inspection, that the control of infection policy be amended to address the use of hand gel, whether it is to be used in the home, and the limitations of its effectiveness. The policy was seen and was acceptable, although a notice displayed in the home about the use of hand gel, did not make it clear that this was to be used in addition, not instead of, hand washing. A member of staff was asked about the use of hand gel, and they were clear that it was to be used to supplement, not replace hand washing. Gloves and aprons were available in all rooms. The home had a new waste management policy in place. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect there will be sufficient numbers of appropriately trained staff on duty to meet their needs. EVIDENCE: There were sufficient staff on duty on the day of the inspection. Two nurses and 7 carers were on duty in the morning on Gainsborough unit. One nurse, two senior carers, 2 carers and a breakfast assistant were on duty in the morning on Constable. The home also has an activities worker who was on duty and who advised that the units join for some activities. There were appropriate Criminal Records Bureau checks on three staff files inspected. The staff file of the worker whom an allegation was made against was inspected. A work permit was in place, as was an enhanced Criminal Records Bureau check. There were no references on file, just one recommendation letter which was not made out specifically to the home. This member of staff had been employed prior to February 2006. Another staff file was inspected and was found to be complete. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 24 A training analysis provided showed that the home had seven senior carers and 24 carers. All seven senior carers had NVQ 2, 3 of these also had level 3 NVQ, and 1 was working towards level 3. Of 24 carers 6 had achieved NVQ level 2, 2 were working towards it. In total 13 out of 31 carers have NVQ level 2, and 2 are working towards it. The analysis indicated that staff are or will, within the year, be up to date in areas of core training including health and safety, manual handling, fire safety, food hygiene. Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users cannot expect the quality of their care and the standard of the home environment to be fully supported by current management and supervision practices. EVIDENCE: A complete application for Registered Manager has not yet been received; the home has been without a Registered Manager since October 2004. There have been two changes in Responsible Person in this period. An action plan had been received following the unannounced inspection in February, completed by the Responsible person. Amongst other matters, this advised that relative’s questionnaires had been recently sent out by the home, Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 26 which would be followed up by a standards group. The Inspector was advised that this is sent directly to Head Quarters, and then feedback on performance and quality is provided to the home. Regulation 26 visits had been carried out regularly and copies of reports forwarded to the CSCI. One inspector was advised that the home had held a relative’s meeting about 18 months ago but that there were no residents meetings held. CSCI service user feed back forms sent to the home prior to the inspection had not been distributed to service users. The home will hold monies for service users if requested. One of the service users tracked had a balance of only 50 pence. Three other service users were selected at random and their monies checked. Cash held balanced with amounts entered on transaction sheets. There were not always two staff signatures for each transaction. There was evidence that the administrator regularly checked balances, and accounts were also audited by the company accountant. Three staff files were inspected for evidence of supervision. One, who was employed in early 2003, had two supervision sessions recorded on file, dated January and March 2006. The other two had no recorded supervisions on file; one was employed in 2004, the other in mid 2005. Service users records were securely stored. A lockable cabinet was in use. The deputy manager advised that it had been established that the cupboard under the stair well in Constable Unit is not a fire door and does not have to be locked. The notice indicating otherwise had been removed. No fire doors were found to be propped open. The refrigerator in the satellite kitchen next to a dining room had food in it that had been made up and started that was not labelled with the date. The home had a fire risk assessment dated November 2005. The maintenance person was spoken with and they confirmed action taken following a requirement made as part of the fire risk assessment. Records showed weekly testing of alarm systems. Portable Electrical appliance checks had been carried out on 20/07/02, and the home had an electrical safety certificated dated 19/05/2005. An accident book was maintained and a summary compiled on a three monthly basis. Catchpole Court Residential And Nursing Home DS0000024351.V297217.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 N/A 3 2 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 N/A 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 N/A 18 3 2 2 2 2 N/A 2 2 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 N/A 2 N/A 2 1 3 1 Catchpole Court Residential And Nursing Home DS0000024351.V297217.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 Standard OP3 Regulation 14(1)(a) Requirement Full assessments must be completed prior to admission, if single assessments are not available, then suitably qualified staff from the home must be used to provide these. The care plan must be completed for a male service user with dementia recently admitted whose behaviour indicates some distress, and fully reviewed with medical opinion sought to contribute to this. A full review meeting, with invited representatives must be held for a service user who is unhappy with their care. Where the planned use of any form of restriction is practiced, it must be in line with an agreed risk assessment and measures agreed and signed by appropriate representatives. This is a repeat requirement from the last two inspections. A significant weight loss must immediately trigger appropriate actions including appropriate monitoring. DS0000024351.V297217.R01.S.doc Timescale for action 31/07/06 2 OP7 15(1), 15(2) 26/06/06 3 OP7 14(2)(a) 31/07/06 4 OP7 13(7), 15(c) 26/06/06 5 OP8 14(2)(b) 31/07/06 Catchpole Court Residential And Nursing Home Version 5.2 Page 29 6 7 OP9 OP10 13(2) 12(4)(a) 8 9 OP10 OP10 16(2)(c) 12(3)(4) & (5)(b) 16(2)(b) 10 OP10 11 OP14 13(7) 12 OP14 13(4)(a) 13 OP19 23(2)(d) 14 OP21 23(2)(n) 15 16 OP22 OP24 23(2)(l) 16(2)(c) Loose tablets must not be kept. Used incontinence pads must not be carried through the building without regard to hygiene or dignity. A screening curtain in a double bedroom must be moved to provide privacy to occupants. The home must ensure that service users are treated with respect at all times and that their wishes are respected. An observation window in a bedroom door must either be fitted with a curtain or blind or be removed. The use of restraint must be limited in line with the mental incapacity bill, which states that any restriction of liberty must be the shortest and least restrictive possible, and regard must be had that the purpose for which it is used can be achieved in any other less restrictive way. This is a repeat requirement from the previous inspection. A Keypad lock in situ at the entrance / exit of the frail elderly unit, Constable, must be removed. The home must ensure the home is reasonably decorated throughout, and advise the CSCI if there is to be any delay to the maintenance plan provided. This requirement was previously, made and is within timescale. Bathrooms should be kept available for use and not used as storage facilities. This is a repeat requirement from two previous inspections. Adequate storage space must be provided. Repairs must be made to furniture and fittings in DS0000024351.V297217.R01.S.doc 26/06/06 14/07/06 15/08/06 26/06/06 15/08/06 26/06/06 21/07/06 31/07/06 31/07/06 31/08/06 31/08/06 Page 30 Catchpole Court Residential And Nursing Home Version 5.2 17 OP24 16(2)(c) 18 19 OP25 OP25 13(4) 23(2)(p) 20 OP26 16(2)(k) 21 OP26 13(3) 22 OP31 CS Act 2000 Sec 11 13(6) 23 OP35 24 25 OP36 OP38 18(2) 13(4) (a) 26 27 OP38 OP38 13(4) (a 13(4) bedrooms on Gainsborough. An audit of beds must be undertaken, and any found to be damaged or stained need to be replaced. A window restrictor must be repaired. CSCI must be informed in writing of the progress the home has made to provide sufficient natural light within rooms 25, 26 and 27. Further action must be taken to rid the home of remaining faint odours in communal areas and maintain the home free from unpleasant odours. To reduce the risk of the spread of infection towels must not be stored in communal bathrooms. This is a repeat requirement from the previous inspection. An application must be made for the homes manager to be Registered. This is a repeat requirement. There must be two staff signatures to witness financial transactions of service users monies. Staff must receive regular formal supervision which is documented. Service users must not have access to hazards in environments where there is work in progress. Broken furniture must not be left where it poses a risk to service users Once opened, food in the fridge must be labelled and dated. 31/07/06 26/06/06 31/07/06 17/07/06 26/06/06 31/07/06 31/07/06 31/08/06 26/06/06 15/07/06 26/06/06 Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP14 OP16 OP19 Good Practice Recommendations Care plans for service users with dementia should contain a life history. Picture menus should be provided for service users with dementia, to encourage participation on choice and stimulate appetites. Key workers should check that all service users have access to a copy of the home’s complaints procedure. The environment for service users with dementia should be developed to better meet their needs, with identifying features on individual rooms, and additional sensory stimulation. All service users rooms on the dementia unit should have photographs or identifying symbols on them. The homes notice on the use of hand gel between attending to service users should clearly state that this is a supplement, not a replacement for hand washing. The results of the service user survey should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. Service users should be asked if they have any views about staff working long shifts at the next service user survey. Regular service user meetings should be held. 5 6 7. OP24 OP26 OP33 8. 9. OP33 OP33 Catchpole Court Residential And Nursing Home DS0000024351.V297217.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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