Inspection on 23/07/09 for St Catharines Residential Home

This inspection was carried out on 23rd July 2009.

CQC found this care home to be providing an Adequate service.

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 28/07/08

St Catharines Residential Home 10/08/06

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 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE St Catharines Residential Home 24 St Catharines Road Broxbourne Hertfordshire EN10 7LE Lead Inspector Yoke-Lan Jackson Key Unannounced Inspection 23rd July 2009 10:00 DS0000019536.V376779.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Catharines Residential Home DS0000019536.V376779.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 stcatharines@bmcarehomes.co.uk B & M Investments Ltd t/a B & M Care Manager post vacant Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2008 Brief Description of the Service: St Catharine’s 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 ensuite 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 home charges £538.98 - £637.00 per week. Further information can be obtained from the Statement of Purpose and the Service User Guide. A copy of the most recent inspection report should be available in the home. St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use the service experience adequate quality outcomes. This unannounced key inspection was carried out on 23/07/2009. The last key inspection was completed in July 2008. The new care home manager and the interim care manager, a care consultant, were present. There are 18 people in residence. The inspection included a tour of the premises, general observation of activities and staff interaction with residents. It also included lunchtime observation. Staff, residents and some visitors were spoken to and key documents were examined. The inspection ended with a thorough discussion with the management team. Survey questionnaires were sent to the residents and relatives and their responses and other information received by us were reviewed. This included the Annual Quality and Assurance Assessment (AQAA) which providers of registered services are required to complete annually. The AQAA focuses on how the outcomes are being met for the people using the service and also provides us with statistical data. What the service does well: Most of the residents appeared relaxed and actively involved in the activities planned for them. A couple of residents seemed to be asleep in their respective armchairs in the lounge for long periods. Residents are generally well cared for. Those spoken to gave positive feedback about the care and service provided. One said, “I am quite pleased with the new managers. They seem to get things done.” Another said, “I am happy in my own little corner. I have my own drinks and the staff are helpful and caring. There are activities but I don’t really like to join in. I enjoy reading my books.” Several residents gave positive feedback about the meals served in the home. Staff interacted well with the residents and assisted them with personal care, social activities and during lunchtime. The residents, their relatives and staff interviewed said that they are very pleased with the change of management and they all expressed their positive support for the new management team. In a recent survey by us, the feedback has been positive and some residents and relatives commented: St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 6 “St Catherine’s feels like a family home. It is a happy home.” “I am well looked after. I am happy with the service. The entertainment is good.” “The staff are always friendly and polite.” “This is a lovely home. The staff are fantastic. There is a lot going on here.” “(My relative) is well cared for here and is happy here.” What has improved since the last inspection? What they could do better: It would appear that many of the issues raised in a recent safeguarding meeting, including the mismanagement of the service, mismanagement of the entertainment funds and non compliance to some of the corporate Policies and Procedures, had not been identified by the provider’s senior management team during their monthly visit under Regulation 26 or during their quality assurance and quality monitoring and audit visits. It would be good if the provider would review their methodology and procedures in regard to their quality assurance and quality monitoring system used to measure success in meeting the aims, objectives and the statement of purpose of the service. This will also ensure the safety and protection of people living in the home. On the day of the inspection, some communal doors were held open manually. This exposes people who live in the home (and staff) to a risk in the event of a fire. All doors should be held open only with automatic hold-open door devices St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 7 that are approved by the Fire Authority. Since the inspection, the management confirmed that these doors will be fitted with the automatic hold-open door devices as soon as possible. There is some refurbishment and repair work to be carried out over the next few months following the review by the provider’s business development manager. Work is in progress to replace all the windows. The management and staff ensure that residents are safe while repair and refurbishment work is being carried out. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Catharines Residential Home DS0000019536.V376779.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 St Catharines Residential Home DS0000019536.V376779.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 (Standard 6 is not applicable) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective clients have the information they need to make an informed choice. A full pre-admission assessment will be carried out before a prospective client is admitted to ensure that the home is able to meet all their care needs. EVIDENCE: The care plan files examined indicated that each resident was assessed fully before being admitted. There is a trial period of stay of 4-6 weeks before the contract is finalised. The new manager is revising the Statement of Purpose and a copy will be forwarded to us as soon as it is completed. St Catharines Residential Home DS0000019536.V376779.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that they will be treated with respect and that their healthcare, personal care and social care needs will be positively met. They will be protected by the home’s medication policy and procedure. EVIDENCE: The residents spoken to seemed happy and satisfied with the care given. One resident remarked, “The care is good. The staff are lovely. I have no complaints.” St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 11 Each person has a written care plan, which forms the basis of care to be delivered. Their health, personal and social care needs are documented in their care plan. The management confirmed that all care plans have been updated. The care plans for three residents were examined and they were found to be detailed and informative. However, in the case of a resident who has Parkinson’s disease, the care plan did not reflect this specific healthcare condition. Since the inspection, the management has updated the care plan to reflect this condition. The home uses a new format for person-centred planning known as the Bethel System, introduced by the provider. Each resident is registered with a local general practitioner of their own choice. Residents have access to appropriate specialist professionals for advice and assistance, including medical, nursing, dental and chiropody services according to their healthcare needs. It was noted that most of the residents are mobile and some are using aids such as zimmer frames, walking sticks and wheelchairs for transport purposes. The management confirmed that the current group of residents do not require the use of a hoist. However, all members of staff have had training on manual handling so that in the event of a fall or a need to use the hoist, members of staff will be able to do so appropriately. A trained member of staff administers the medication in accordance with the home’s Medication Policy and Procedures. The home uses the monitored dosage system and the medicines that are in use are stored in the drug trolley that is securely attached to the wall when not in use. The home has a controlled drug cupboard. The management audits medication daily. The medication administrative record (MAR) charts were examined and they were found to be correctly filled in. No gaps were found. The home manager confirmed that there have been no medication errors under the new management. St Catharines Residential Home DS0000019536.V376779.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service will be given assistance to exercise choice and control over their lives and their preferences will be respected. They will be encouraged to have close links with their friends and relatives and they will be provided with a choice of menu and be encouraged to have a healthy diet. EVIDENCE: The daily routine in the home and the activities provided are flexible and varied to suit individual expectations and preferences. Members of staff interviewed said that they help out with activities as the home has no full time activity coordinator. However, there is an activity person who assists every Thursday. The home manager confirmed that the service has advertised for an activity co-ordinator. St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 13 There are planned activities each week, such as music and movement, games and quizzes, cake decoration, drawing and painting. Individuals are encouraged to have daily walking exercise. Outings and trips are arranged depending on the weather conditions. The social activities are recorded in each resident’s care plan. On the day of the site visit, there was an activity service known as Pets as Therapy, whereby a volunteer brought along two dogs and residents were encouraged to stroke these pet dogs and the volunteer gave one-to-one attention to interested residents. It was noted that some residents were involved with cake decoration and these freshly baked cakes were then offered to all during teatime. Some residents were encouraged to play board games. Members of staff were involved in the activities and there was one-to-one stimulation for some residents. It was noted that one resident had been asleep in an armchair in the lounge for most of the time before lunch. The same resident has a bent over posture against the side of the armchair. A member of staff interviewed said that this has been the routine for the resident for some time. The same resident was then woken up and assisted by two members of staff for a walk in the garden followed by lunch in the dining room. The new home manager said that she will carry out a risk assessment and will review the situation to see whether a recliner chair might be more suitable for this resident. Residents have close links with their relatives and friends. On the day of the site visit, one of the residents was taken out to lunch by a family member. Another resident was visited by a relative who sat with them as they play a game of scrabble. Lunchtime was unhurried. The majority of the residents had their lunch in the dining room while three ate in the second lounge. Residents are generally pleased with the food provided. The chef who was present on the day of the site visit confirmed that residents are given a choice of two hot dishes each day and residents are involved in the selection of the menu that is planned in advance. The menu for the day was on display on the wall in the dining area. One resident remarked that they had difficulty reading the printed menu on display. The management has since rectified this problem. St Catharines Residential Home DS0000019536.V376779.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that the home has a robust Complaints’ Policy and Procedure and that they will be listened to and any concerns raised will be rectified as soon as possible. EVIDENCE: The home follows the Hertfordshire County Council Adult Care Services Safeguarding Procedure. In February 2009, there was an anonymous complaint made to Hertfordshire County Council Adult Care Services and the Primary Care Trust and a copy of this complaint was forwarded to us. This resulted in safeguarding meetings and investigations being held under the joint agency safeguarding procedures. The allegations of verbal abuse of residents, poor moving and handling procedures, disregard of residents’ privacy and dignity, an altercation between two workers that resulted in the police being called to the premises, were all substantiated except the allegations of verbal abuse and moving and handling. Further investigation under the safeguarding procedure had revealed poor care practices, poor moving and handling training for staff, poor record keeping, St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 15 poor staff record or lack of staff supervision and poor management of the service. It would appear that many of the issues raised during the investigation had not been identified by the provider’s senior management team during their monthly visit under Regulation 26. In April, the provider took action and replaced the home manager (and the deputy manager) and put in a contingency plan using the service of a care consultant to address all the shortfalls highlighted by the safeguarding team. This ensures the health and safety of all the residents. There was a short period of embargo by Hertfordshire County Council which was lifted when all the shortfalls highlighted had been addressed by the provider. The home is not involved in the financial affairs of the residents. Where individual residents wished to purchase items the staff team facilitate this from the petty cash on residents’ behalf and the service invoices families and advocates monthly. However, under the previous manager, there was a mismanagement of the service’s entertainment funds which has since been rectified by the provider. The charge of £10 per month on top of the fees charged has since been discontinued following the safeguarding investigation. St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22, 24 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that they live in a homely and comfortable environment. However, some doors have been held open manually which put people at risk in the event of a fire. EVIDENCE: Residents have access to all communal areas. The lift is operational and aids such as zimmer frames and wheelchairs are available to help residents move around. The interior of the home is generally clean and tidy. On the day of the site visit, the local mayor and her team were on site as judges for the St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 17 competition to find the best garden in the area. St Catharine’s had won awards a few times. On the day of the inspection, the provider’s Business Development Manager was in the home conducting an annual review of the premises and the fixtures and fittings to ensure that the premises are well-maintained. A copy of the list of recommendations for improvement over the next 6 to 12 months was submitted to us. Building work to replace the windows is in progress and there are hazard warning signs around where the scaffolding is being used. The management and staff ensure that residents are safe while repair and refurbishment work is being carried out. It was noted that a number of doors were held open with wedges, namely, the doors in the two lounges and the door from the entrance hall to the corridor. This exposes people who live in the home (and staff) to risk for their lives in the event of a fire. Members of staff removed the manual wedges as soon as this was highlighted. The management assured us that these doors will be fixed with automatic hold-open door devices within the next few days. St Catharines Residential Home DS0000019536.V376779.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that the new management will follow the home’s recruitment policy and procedures when employing new staff to ensure people who use the service are safely cared for. They can be assured that staff will have the appropriate training to enable them to meet the care needs of people living in the home. EVIDENCE: The interim care manager, a care consultant, had addressed all the shortfalls identified in a recent safeguarding meeting. These shortfalls included poor management of formal staff supervision, poor staff training record updates, an inadequate system in dealing with positive Criminal Investigation Bureau (CRB) checks on new staff recruited. There was also poor standard of moving and handling training. All members of staff have had updated training since then in Moving and Handling, Medication Administration, Infection Control and the Protection of Vulnerable Adult (POVA) including the Hertfordshire County Council Joint Safeguarding Procedure and Whistle-Blowing Policy. The members of staff interviewed confirmed that they have had the training. St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 19 The two new managers confirmed that they had their Criminal Record Bureau checks done and also the Protection of Vulnerable Adult (POVA) checks and clearance prior to commencing work in the home. They also confirmed that they are currently attending the management induction programme for new staff. On the day of the inspection, the staffing level was adequate for the current group of residents. Members of staff interviewed said that they are very pleased to be working under a new management team and that staff morale has improved since the change of management. The service is currently advertising for an additional activity-co-ordinator as the existing arrangement is with a contract activity person who helps out one day a week. Staff, however, assist with activities. St Catharines Residential Home DS0000019536.V376779.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of management remains to be proven. People who use the service can be assured that the service will continue to improve under the new management and that their health, safety and welfare will be promoted and protected. EVIDENCE: This service is currently without a registered manager. It was temporarily managed by an interim manager, a care consultant, from April 2009 until the appointment of a new home manager and deputy manager in July 2009. St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 21 As the new home manager took up the post on 13/07/2009, two weeks before this inspection, it is not possible to assess the quality of management during this inspection. However, the new manager was an experienced home manager in her previous appointment. The new management team are currently being inducted with the support of the interim manager. The new home manager has yet to register with us. Under the interim manager, the standards of administration and management of the service have improved. Care plans have been revised and updated and where appropriate, risk assessments have been carried out. The training programme for staff has been revised to ensure that the staff are appropriately trained to meet the needs of the residents, especially in Moving and Handling, Whistle-Blowing and Safeguarding. Staff have been reminded to treat residents with respect and dignity. Most of the staff have had formal supervision and the staff files have been updated to reflect the supervision that had been carried out. Evidence of this was seen in some of the staff files examined. The home manager will ensure that all staff have regular formal supervisions and an annual appraisal. All records, including servicing records, for the protection of the residents have been updated. Under the previous management, the service was charging each resident an extra £10 per month as a contribution towards entertainment and certain activities. The money was in a pooled account. This practice has since been discontinued following the recent safeguarding meeting. During the site visit, a relative interviewed confirmed that £10 was taken off their account every month since admission. It seemed the relative was not aware that this practice has discontinued. The interim manager had confirmed that a letter to clarify the issue has recently gone out from the provider to all the residents and their relatives. On the day of the site visit, the care consultant and the new managers were present. The residents, their relatives and staff interviewed said that they are very pleased with the change of management and they all expressed their positive support for the new management team. It would appear that many of the issues raised in a recent safeguarding meeting, including non-compliance of the corporate Policies and Procedures on the recruitment of staff with positive CRB checks, management of entertainment funds, staff training and formal supervision of staff, had not been identified by the provider’s senior management team at their monthly visit under Regulation 26 or during their quality assurance and quality monitoring and audit visits. St Catharines Residential Home DS0000019536.V376779.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 3 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 2 2 x x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 x 2 St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP18 Good Practice Recommendations It is recommended that all staff have regular refresher course on the Hertfordshire County Council Safeguarding Procedure, the Protection of Vulnerable Adult (POVA) issues and the Whistle-Blowing Policy, in order to ensure that people living in the home are protected and safeguarded from abuse. It is recommended that all doors that need to be kept open be fixed with automatic hold-open door devices, approved by the Fire Authority, as soon as possible. Until then these doors should be kept close at all times to minimize risk in the event of a fire. It is recommended that the provider review their methodology and procedures in regard to their quality assurance and quality monitoring system use to measure success in meeting the aims, objectives and the statement of purpose of the service. DS0000019536.V376779.R01.S.doc Version 5.2 Page 24 2 OP19 3 OP33 St Catharines Residential Home St Catharines Residential Home DS0000019536.V376779.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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