Inspection on 19/12/05 for St Catharines Residential Home

This inspection was carried out on 19th December 2005.

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

Other inspections for this house

St Catharines Residential Home 23/07/09

St Catharines Residential Home 28/07/08

St Catharines Residential Home 10/08/06

St Catharines Residential Home 13/09/05

St Catharines Residential Home 15/10/04

St Catharines Residential Home 29/06/04

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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 Jan Sheppard Unannounced Inspection 19th December 2005 10:00 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.V270409.R01.S.doc Version 5.0 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.V270409.R01.S.doc Version 5.0 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 janice.pittom4@btinternet.com B & M Investments Limited (Trading as B & M Care) 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.V270409.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 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. There are 19 single bedrooms, 6 of which have en-suite facilities and 4 double bedrooms of which 2 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. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of this inspection year and took place over one day when residents staff and visitors were spoken with, care plans and other records examined and a partial tour of the building undertaken. The statements in this report reflect what was observed by the inspector on that day. Not all of the standards were examined as they were all inspected during the previous inspection on 13th September 2005 to which reference may be made. On the day of this inspection the home had a calm and welcoming atmosphere with care seen to be being delivered in an unobtrusive manner which enabled the residents to retain their own abilities as far as this was safely possible for them to do. Positive comments were made by residents and their visitors concerning the care and services offered by the home. What the service does well: What has improved since the last inspection? Since the last inspection changes made to the personnel and arrangements in the kitchen including revised menus are being appreciated very much by the residents many of whom told the inspector that the food had greatly improved over recent months. Since the last inspection the variety of activities that are offered to the residents has increased. Areas of the home including residents bedrooms have been redecorated this maintaining the high standards of appointment offered by this home. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 6 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.V270409.R01.S.doc Version 5.0 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.V270409.R01.S.doc Version 5.0 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): 1&5 Standard 6 is not applicable to this home, as intermediate care is not offered. Information offered to prospective residents and their families is comprehensive and informative enabling an informed decision about admission to be made. All prospective residents and their families are given the opportunity to visit the home before admission arrangements are discussed. EVIDENCE: There have been no changes to the information given to prospective residents nor in the pre admission assessment procedures carried out by the home since the last inspection. All prospective new residents are visited at home by the manager or deputy manager so that a full assessment of their needs can to made. The homes records relating to recently admitted residents confirmed that these procedures had been carried out and those residents spoken with said that the process of their admission had been handled sensitively. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 9 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): 7,9 and 10. Adequate care plans are kept for all residents. The residents records evidenced that their care and health needs were being met with assistance sought from Doctors and other medical specialists when needed. Extra care needs to be maintained concerning the accuracy of the medication administration records. Care was seen to be being delivered by trained and experienced staff in a kindly unobtrusive and sensitive manner enabling individual need to be met whilst maintaining dignity and respect for the resident. EVIDENCE: Without exception all the residents spoken with said that they were well cared for by the staff whom they knew well. One said, “ they are all very kind and so helpful nothing is too much trouble for them “. A number of care plans were examined and these were found to contain good detail to be well maintained and to be subject to regular reviews. Risk assessments were present on each plan as were notes of any care offered by a visiting District Nurse. On the day of this inspection two District Nurses visited the home to offer pre planned care to individual residents. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 10 There have been no changes in the arrangements for the storage and administration of medication since the last inspection. An examination of the MAR sheets, medication administration records, revealed some errors in recording including omissions in recording. One liquid medication was found to be being stored at the incorrect temperature and several loose packets and bottles of medication had not had their opening dates recorded. Requirements are made. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 11 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 and 15. A wide and varied activities programme is offered and this tries to accommodate everyone’s individual preferences. Feedback and suggestions are sought on all aspects, this promoting autonomy and choice. Visitors are always welcome in the home. All the residents were complimentary about the recent changes made to the menus. EVIDENCE: Since the last inspection there have been some changes in the activity programmes offered within the home. This has resulted because of resignations due to retirement and relocation of some of the teachers/ activity organisers. The manager has worked hard in recruiting replacements and has taken this opportunity to consult with the residents concerning their wishes and requests for different activities. On the day of this inspection two separate activities offered by external staff were offered as well as the homes staff seen to be assisting a small knitting group. Residents confirmed to the inspector that it is left entirely up to them whether they participate or not. One resident said that she never joined is as she preferred to read quietly or to watch television alone in her room whilst another confirmed that she enjoyed some class or activity every day. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 12 Without exception all the residents were very complimentary about the changes that the new cook has introduced to the menus. One resident told the inspector that “ she comes to talk with us regularly about the food served and asks for our suggestions about new dishes, Mrs.X (another resident) helped the cooks make the Christmas cakes and puddings.” One resident who whilst confirming that the choices of dishes was excellent did mention that she would like more fresh fruit to be available on a daily basis. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 13 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 and 18 The home has a robust complaints procedure and follows the Adult Protection Procedures as set out in Hertfordshire’s Joint Agency guidelines. EVIDENCE: Copies of the homes complaints procedure were seen in the entrance hallway along with the latest inspection report and a good practice suggestion box. One complaint made since the last inspection was seen to have been properly dealt with. Several residents confirmed to the inspector that they knew about the complaints procedure and how to formally activate this. However they all said that they would first speak with the manager or other staff who were all very approachable and who always endeavoured to sort things out quickly. There have been no incidents relating to Adult Abuse since the last inspection and the manager confirmed that to her knowledge the home has never had such an incident. The homes training records evidence that training on this subject, and on Whistle Blowing, is on going. Staff spoken with demonstrated an awareness of the various aspects of this subject. However as neither the new manager nor deputy manager have ever had the experience of managing any allegation of abuse nor have they had any experience of the procedures involved it is a requirement that they undertake further training to up date their knowledge of this subject. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 14 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): 19,23 and 26 The home and its surroundings offer a pleasant, comfortable safe and homely environment for its residents. The home is kept very clean is well maintained and the bedrooms are personalised offering a homely, lived in feel. The home generally meets the space and environmental requirements for this standard except for one double bedroom, which does not meet the space requirement. EVIDENCE: All the residents who were spoken with expressed their satisfaction with their rooms and the manner in which the staff assisted them to personalize these with pictures ornaments and small items of their own furniture. Recent redecorations were seen to have been according to the choices of colours patterns and soft furnishings made by the resident. The manager was able to demonstrate that a routine maintenance programme is operated in the home and she discussed various plans for further works to be undertaken during the coming year. On the day of this unannounced inspection the home was found to be very clean and tidy with no offensive odours. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 15 It continues to be a requirement that when a vacancy occurs in the undersized ground floor double bedroom that it reverts to single occupation. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 16 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): 27,29 and 30. On the day of this inspection the home had adequate staff on duty to meet the needs of the residents. Staff are experienced and undertake regular training. Robust staff recruitment procedures are in place to ensure the safety of the residents, however one lapse in these arrangements was noted. EVIDENCE: The staff were seen to be working well together as a team and to be enthusiastic about their work. The home continues to retain a very stable staff group many of whom have worked at the home for many years. No member of staff has left since the last inspection and consequently no new members of staff have been appointed although some staff, the cook included, have changed their working roles and extended their hours. It is a requirement that an up to date CRB record for one part time sessional worker is obtained. Staff confirmed to the inspector that they are well supported by the homes managers and attend regular supervision meetings during which their training needs are discussed. The records evidenced that the home has compiled an annual training plan for the home from these individual training needs plans. Since the last inspection two more staff have commenced studying for NVQ at level 3 and four others have completed their NVQ level 2 courses. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 17 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): 33 and 36 The home is managed by experienced staff many who have worked there for many years and who regularly undertake training. The residents interests and safety are supported by the good maintenance of the homes records and the following of procedures concerning risk and safety. EVIDENCE: The staff were observed to be working well together with good team working and told the inspector that the best interests of the residents was their priority. Staff confirmed that they receive regular supervision and are well supported by the homes managers. Regular visits are made to the home by a representative of the company. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 18 The recently appointed homes manager who had previously worked at the home in a deputy manager capacity for many years, has commenced the NVQ level 4 and Registered Managers Award qualification. Since the last inspection she has attended a number of other training courses to enable her to attain the required supervision and disciplinary management skills needed for her new role. The fire records were checked and confirmed that regular tests and fire drills are carried out. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 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 2 3 x x x 2 x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x 3 x x St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 20 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 OP23 Regulation 23(2)(f) Requirement The undersized bedroom, (number 1), is not used for double occupancy for any new resident. This requirement from the previous inspection has not yet been met. The new manager and deputy manager must attend further training concerning Adult Protection and Whistle Blowing. Accurate MAR medication administration records must be kept and liquid medication must be stored at the correct temperature. All staff working in the home whether full or part time, must have a current CRB check Timescale for action 31/03/06 2. OP18 18(1)(c) (i) 30/06/06 3. OP9 13(2) 01/01/06 4. OP29 19 (1) (a) 01/01/06 St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 21 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 OP15 Good Practice Recommendations Fresh fruit should be made available for all residents to meet their wishes and requirements. St Catharines Residential Home DS0000019536.V270409.R01.S.doc Version 5.0 Page 22 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.V270409.R01.S.doc Version 5.0 Page 23 - 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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