Inspection on 10/08/06 for St Catharines Residential Home

This inspection was carried out on 10th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Catharines Residential Home 23/07/09

St Catharines Residential Home 28/07/08

St Catharines Residential Home 19/12/05

St Catharines Residential Home 13/09/05

St Catharines Residential Home 15/10/04

St Catharines Residential Home 29/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Catharines Residential Home 24 St Catharines Road Broxbourne Hertfordshire EN10 7LE Lead Inspector Mrs Sheila Knopp Unannounced Inspection 10 August 2006 10:55 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 St Catharines Residential Home DS0000019536.V306480.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. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catharines Residential Home Address 24 St Catharines Road Broxbourne Hertfordshire EN10 7LE 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) 01992 462224 01992 442 632 B & M Investments Limited (Trading as B & M Care) Tracy Shambrook Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: St Catharines is a large detached property situated in a quiet residential area of Broxbourne. It was first registered as a residential home under the Registered Homes Act in 1983 when it was converted to provide accommodation on three floors all of which are accessible by a lift. Three bedrooms on the first floor are reached by a further short flight of steps. There are 19 single bedrooms, 6 of which have en-suite facilities and 3 double bedrooms, which have en-suite facilities. On the ground floor there are two lounges, a separate dining room, a conservatory, the kitchen and a small office. The home has very attractive landscaped gardens with pathways and a patio area. The home is easily accessible for the local shops and there is a range of bus and rail links nearby. The home, which is owned by B&M Care Ltd, provides a warm, secure and caring environment for its elderly residents in a very homely setting. The current fees for single rooms range from £500 - £600 per week based on an individual assessment of need (correct as of 10.8.06). The rate for double (shared) rooms ranges from £450 - £475 per week. An additional charge of £10 per month is made as a contribution towards the cost of entertainment. Information about the home is contained in the Service User Guide & Statement of Purpose, which are available on request from the manager. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced visit to the home on 10 August 2006. Information from discussion with 12 service users individually and in groups, 3 relatives visiting 2 service users, 2 staff and the manager as well as a review of case records (3) and management records has been used to assess the service provided at St Catherine’s. Information received about the home since the last inspection on 19 December 2005 has also been reviewed. The Commission sent questionnaires directly to 10 residents and relatives. Responses and comments received in July from 7 residents and 9 relatives have been reviewed and included in this report. Questionnaires were also received from 2 general practitioners (GPs). What the service does well: What has improved since the last inspection? St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 6 Since the last inspection the manager has been confirmed in her post by the Commission as required under the Care Standards Act. The improvement in meals reported at the last inspection under the new cook has continued. The cook takes an active role with residents promoting the importance of meal times and in some cases enabling them to cook and put together favourite recipes. An undersized double room has been converted to single use providing a better environment for people who will live in this room. 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. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 the following standard(s): 3 – Standard 6 does not apply to this service. Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. New residents only come to live at St Catherines after their needs have been assessed by the manager and they and their relatives have had the opportunity to visit the home and meet with other residents and staff. A relative said ‘ Although very professional both the staff and the home have a very caring and very home-like feel’. EVIDENCE: A new resident felt very positive about the move to St Catherines and felt supported by the staff and included by the other residents. They had visited to home before coming to stay. Their records confirmed that an assessment had been carried out and information obtained from other health & social care professionals. Family members looking for a place for their relative are invited to meet residents and staff and to have a meal. A relative confirmed they were shown around and were able to ‘chat with residents and staff’. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 9 Another relative confirmed they had discussed special needs with the manager. All residents and relatives who completed comment cards said they had received enough information to decide if St Catharines was the right place for them. The residents and relatives who completed questionnaires confirmed they were issued with contracts. B & M Care have taken the positive step of changing Room 1 into a single room as it is too small to be a double room. A new certificate needs to be issued to reflect this change. The manager reported there are other areas that are also being updated in the Service User Guide and Statement of Purpose and agreed to provide copies to the Commission as required by legislation. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Residents have their needs met in a sensitive and discrete manner by staff who they are familiar with and understand how they like to be supported. Residents have access to medical services and there are systems in place to ensure their medicines are managed safely. EVIDENCE: The needs of service users are set out in a plan of care which service users and or their representatives sign. Two GP’s who completed questionnaires confirmed that staff demonstrated a clear understanding of the care needs of residents, there was always a senior member of staff to discuss things with and medication was appropriately managed. They confirmed they were satisfied with the overall care provided at St Catharines. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 11 All the service users spoken to on the day of inspection were positive about the care and support they receive. All residents who completed comment cards said that staff listen to them and act on what they say. Residents are supported by an experienced and consistent team of staff. It was suggested as a future development that the manager includes updates in the training programme on specific issues such as diabetes, stroke management and Parkinsons disease as these have not been covered for some time. Staff receive training to support people who have been bereaved. The community nurses provide support to residents and staff. Pressure relieving equipment and aids to mobility are obtained when required and were seen to be available. It was reported that no residents had pressure sores, which, indicates good standards of care are being provided. The systems for managing medication were reviewed and found to be satisfactory. The competence of staff to give out medicines is assessed by the manager and dispensing pharmacist and reviewed at regular intervals. Service users are supported to continue to manage their own medication. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Residents are supported to continue to live stimulating lives and maintain contact with family and friends. Nutritious and well-presented meals are served. EVIDENCE: Residents are encouraged to make choices about their life at St Catherines and be actively involved in the running of the home and part of the wider community. Their views are obtained individually and at regular coffee mornings. Residents described a visit to a local market and how they had enjoyed making their own purchases. One person came back and told other residents about changes that had taken place. Three residents represented the home when it recently won the Broxbourne ‘Garden in Bloom’ competition. As well as staff who organise activities within the home outside entertainers are brought in. A range of things to do are provided to suit differing tastes. Information about activities, news and events are displayed on busy notice boards in the entrance hall. One person said the appreciated the large print books changed regularly by the library service. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 13 Some residents acknowledge that they prefer to be in their rooms and their wishes not to be involved in planned events are respected. Family and friends feel welcome and know they can visit the home at any time. There are also visitors from the wider community such as church representatives. Where able residents are encouraged to manage their own financial affairs. There are policies in place, which restrict staff involvement with financial matters at which point the resident’s representative or advocate would be involved. Residents are able to personalise their rooms with familiar and important items from home. On the day of inspection a high level of satisfaction with the choice and quality of meals served was expressed. Staff recognise the importance of making meal times an important part of the day to be looked forward to. Residents are able to have their meals in the dining room or their own room if they wish. Regular drinks are available and staff will always make a cup of tea for residents and their visitors. Fresh fruit was available for residents to pick up and snacks are provided with the late evening drinks. The cook meets regularly with residents individually and as part of the regular coffee morning group. She is also involved with residents who like to cook and is aware of the role of cooking in the life of residents, for example bringing out fresh hot scones to sample as they come out of the oven. Staff were observed providing sensitive support to those who needed assistance or help cutting up their food. Special diets and preferences are catered for. The last visit by an Environmental Health Officer was on 23.9.05 and there are no outstanding issues. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. The views and concerns of residents and their relatives are listened to and when required there is a formal complaints procedure in place. Staff receive training in how to protect residents from abuse and confirm they are able to raise any issues or concerns is an open manner. EVIDENCE: The home has a low number of complaints. Residents feel safe and well cared for. All relatives who completed questionnaires confirmed they knew who to make a complaint to. Six out of 7 residents said they always or usually knew who to make a complaint to. The complaint procedure is available to residents and their visitors and sets out the timescales within which a response should be received and what action to take if they remain dissatisfied. Staff receive training in protecting residents from abuse and know the procedures to follow should they have any concerns. The Hertfordshire multiagency adult protection procedure is available in the home for reference. No concerns have been raised under this procedure regarding the care and well being of residents. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 the following standard(s): 19 & 26 Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. St Catherines provides residents with accommodation in pleasant, comfortable, and homely surroundings. Overall there are good systems in place to ensure the safety of residents however the cracked panes of glass in the front door need to be replaced. The manager has been advised to review the agreements where two people share a room so they are offered the choice of a single room when one becomes vacant. All areas of the home were found to be fresh and clean. A requirement to review the hand washing provision for staff to prevent the spread of infection has been made as appropriate liquid soap and paper hand towels were not available in areas where staff carry out personal care. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 16 EVIDENCE: There are a variety of day areas for residents to sit in during the day and the garden, which regularly wins awards, is much appreciated. Low cane style furniture is provided in the conservatory which residents confirmed was comfortable and groups were seen making good use of this area during the day. Two relatives raised concerns about lack of access to the garden. Staff report that they accompany residents who need assistance but have now provided a horn so that residents can attract some ones attention if they are on their own. B & M Care may wish to consider reviewing their call system to enable a mobile handset or pendant alarms to be added to it. There are a number of shared rooms at St Catherines and it was not clear from discussion with the manager that residents are given the choice to move into a single room when one becomes vacant. This needs to be clarified as part of the sharing agreement agreed on admission with the service users concerned. In the case of vacancy in a room shared by a couple consideration should be given to maintaining this room as a single room until no longer required or offering a single room at an appropriate interval. The service and maintenance records confirmed that there is a planned programme of redecoration and refurbishment in place. Individual rooms have been decorated and carpets replaced since the last inspection. However it is of concern that two small leaded panes of glass in the front door have been broken for sometime and not replaced. One of the bathrooms is used infrequently because of the style of bath. B & M may wish to consider upgrading this area by providing a more suitable bath or shower. Window restrictors and radiator covers are in place to protect residents from accidents. It was reported that the external windows are due to be replaced. Hot water temperatures are tested to ensure residents are not at risk from accidental scalding. The hot water tested at the time of the inspection was within the required safety range. A high level of satisfaction with the standard of housekeeping was expressed by residents and their relatives. A resident said the ‘cleaners are first class and glad to help in anyway’. Staff do not currently have access to liquid soap and paper hand towels when they are providing personal care in individual bedrooms. Having to go through several doors to an area where they can wash their hands increases the risk of spreading infection. It is advised that liquid soap containers are of the cassette or pump type as refilling can introduce infection. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 17 Hand towels should be of the soft variety to prevent skin abrasions, which can increase the risk of infections. Further advice can be obtained from the Community Infection Control Nurses. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 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 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 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a consistent and well-trained team of staff who are familiar with their needs. Recruitment checks are carried out on staff before they start work in the home to ensure residents are protected from people who are not suitable to work with vulnerable people. A requirement made following the last inspection regarding ensuring all staff including volunteers had criminal record bureau checks has been met. EVIDENCE: The rotas indicate that suitable numbers of management, care and support staff are provided for the number of residents in the home. At the time of this inspection the home was fully staffed. Staff are able to cover shifts where needed and agency staff are not required. There is good interaction between staff and service users and residents confirmed they got on well with staff. The staff interviewed by the inspector demonstrated a commitment to providing a good quality of care to the residents. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 19 B & M Care have demonstrated a commitment to ensuring staff receive training at an appropriate level and in accordance to guidance for training social care workers. Fifty percent of the care staff have achieved qualifications at NVQ level 2 The records of 4 staff which included a new member of staff and a volunteer were reviewed and the required information including two references and a criminal records bureau check were available. Only one new member of staff has been appointed since the last inspection. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. St Catherines is a well managed home and has a good reputation. Residents and staff also receive support form B & M Care’s senior management team who monitor the quality of the service being provided. Since the last inspection Ms Shambrook has been confirmed in her position as registered manager by the Commission. Standard 31 will be fully met when she has completed the qualifications set down for registered managers to achieve within 2 years of registration. EVIDENCE: The registered manage is completing the Registered Managers Award and will also require an NVQ in care at level 4. Since the last inspection she has also attended management training courses to support her in her role. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 21 Staff receive regular supervision and support to carry out their roles. They confirmed that staff worked as a team. There is a training programme in place to ensure staff receive the required statutory training to maintain the safety of service users. Staff can provide support for residents to manage their own finances but do not hold money on their behalf. There are quality assurance systems in place, which review the quality of care provided and seek the views of residents and their relatives. There are health & safety auditing systems in place. Records relating to health & safety, fire precautions and accidents and incidents were seen to be properly maintained. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 22 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 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 x 3 x x 3 St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP23 Regulation 23(2)(f) Requirement Provide written confirmation that room 1 is designated for single occupancy only and the number of places has reduced to 25. Replace the broken panes of glass in the front door. Provide liquid soap and paper hand towels for staff in all areas where personal care is carried out - Infection Control Guidance for Care Homes (DoH June 2006). Timescale for action 30/09/06 2. 3. OP19 OP26 23(2)(b) 13(3) 30/09/06 30/09/06 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 OP23 Good Practice Recommendations Clarify the policy on double rooms to demonstrate that where rooms are shared both residents have made a positive choice to do so and when a shared place becomes vacant the remaining resident has the opportunity not to share or be offered a single room at an appropriate time. St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 St Catharines Residential Home DS0000019536.V306480.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!