Inspection on 28/07/08 for St Catharines Residential Home

This inspection was carried out on 28th July 2008.

CSCI 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 23/07/09

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE St Catharines Residential Home 24 St Catharines Road Broxbourne Hertfordshire EN10 7LE Lead Inspector Jane Greaves Unannounced Inspection 28th July 2008 10:30 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.V369087.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.V369087.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 Tracy Shambrook 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.V369087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2006 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 fees for personal care and accommodation range from £387 to £652 per week based on an individual assessment of need (correct as of 30th July 2008). 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.V369087.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 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced site visit. At this visit we looked at how well the service meets the needs of the people living at St. Catharines and how staff and management support people to have a lifestyle that is acceptable to them. The level of compliance with requirements made at the previous inspection was assessed. The site visit took place over a period of eight hours. A tour of the premises was undertaken, care records, staff records, medication records and other documentation were selected and various elements of these assessed. Time was spent talking to, observing and interacting with people living at the home, and talking to staff. Prior to the site visit the manager had completed and sent in to us (the Commission for Social Care Inspection) the home’s Annual Quality Assurance Assessment (AQAA). This provided detail of how the service feels they are performing against the National Minimum Standards, and how they can evidence this. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives, involved professionals and staff. The views expressed in survey responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the manager, staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: Visitors are always made welcome. Relatives felt that staff communicated with them well and kept them up to date with any issues concerning their relative. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 6 Staff members were caring in their approach. Relatives felt that what the home did well was, ‘Provides a real home for X not just a Care Home. X is wonderfully looked after with real attention and is always treated with dignity and respect’ and ‘the rooms are generally clean and well kept and the residents are well fed’ and ‘They make their residents feel that St. Catharines is their home.’ People spoken with reported that they liked the home. They said that the food was good. What has improved since the last inspection? What they could do better: The home’s Statement of Purpose and Service User Guide should accurately reflect the service provision, be up to date and available in suitable formats to meet peoples’ needs. This is so people can make an informed decision about the service provided at the home and whether the home will be suitable for them. Daily recording needs to include more detail to confirm that support is being provided according to each persons’ indivuals needs and choices. Risk assessments need to be reviewed regularly in conjunction with the care plans to ensure that changes in individuals’ needs and circumstances do not impact on their general safety and well being. In order to ensure that medication procedures in the home promote and protect the health, safety and welfare of people, records need to provide an accurate audit trail of what medication is given to individuals, at what time and by whom. Although staff take an active role in providing stimulation and activity for people, this area needs to be developed. Peoples’ occupational and activity needs should be properly assessed and met on an individual basis. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 7 Some areas of the home are poorly maintained and this detracts from the overall environment, does not respect peoples’ dignity and may even pose potential risks to the safety of residents and staff. 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. The summary of this inspection report can be made available in other formats on request. St Catharines Residential Home DS0000019536.V369087.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.V369087.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to move into the home can be assured that their needs will be assessed to make sure that the home will be suitable for them. They cannot be sure to have access to accurate written information about the home to help them to make an informed choice. EVIDENCE: The service had a Statement of Purpose and Service User Guide designed to provide the information necessary for people considering using the service to make an informed decision. We noted that the Service User Guide did not contain information about what the service would do in response to anyone making a complaint. The Service User Guide stated that residents’ meetings took place regularly. The Manager reported that this was not accurate. Experience had shown that the people living at the home were not comfortable with large meetings but they had coffee mornings instead, these were not documented. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 10 We looked at care plans for two people recently admitted to the home. These showed us that the manager and deputy visited people at home or in hospital to undertake an assessment of their needs to be sure St Catharines would be able to provide the care and support that the person needed. The manager reported that peoples’ families and nursing professionals were involved in this initial assessment where possible and evidence was seen in the care plans to confirm this. The pre admission assessments included all areas of daily life, personal care and medical support that individuals needed and these were then used to develop a care plan for care staff to follow. The service recognises that peoples’ mobility needs were important, as the home was difficult to move around for people with limited mobility. The service does not offer intermediate care. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff members are successful in delivering appropriate care, although this may not always be documented appropriately. People cannot be confident that their medication will be properly and safely managed. EVIDENCE: We looked at care plans for four people living at the home. There was evidence to show that monthly reviews were undertaken of all areas of each person’s care plan at the end of each month. Senior care staff performed the reviews using information from the daily reports and doctors’ notes. Daily records reported that one person needed cream applied to sore areas of skin. This was identified in April and daily records continued to include reference to this at the point of this visit. There was no care plan in place to deal with this and no record of the home obtaining medical attention for this person. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 12 One care plan we looked at stated that the person needed assistance with all personal care but contained limited information as to how the personal care needed to be delivered. Risk assessments relating to areas such as falls, moving and handling, nutrition and weight loss were included in care plans and, in some cases were signed by residents. Risk assessments did not have a date set for review, it was reported that they were only reviewed when something had changed. Staff acknowledged that small changes in care plans from month to month could add up to significant changes over a period of time and may well affect the risks that people were susceptible to. There was some inconsistency in record keeping, some people had signed consent for staff members to give them medication and others had not. Some risk assessments had been signed and dated to show who had undertaken the assessment and when it had been done and others had not. One file we looked at did not include a photograph of the person. Daily records contained comments such as ‘fine’ and slept well’, there was no detail describing the day the person had spent, what their demeanour was or what they had done to fill their day. Staff reported that very few residents had the capacity to sign and understand their care plans and family members generally needed considerable encouragement to be involved with care plans. Senior staff were responsible for care planning documentation but didn’t have dedicated time to enable this to happen. There were three staff on duty at each day shift and staff reported that this did not allow for accurate and detailed care plan recording. It was noted there was no space away from communal areas for staff to deal with confidential paperwork. Staff demonstrated they had a great deal of information held in their heads about the residents however this was not being transferred to care plans. People living at the home told us they were satisfied with the way the home catered for their medical needs. Comments received via completed surveys included, “If I should need medical attention the management will always make sure you receive their best attention and get the doctor to call and make sure all is well with me”. The service had a good working relationship with the community district nursing team who provided incontinence advice to the home. It was reported there were no people with pressure sores at the time of this visit. Medication maintained on behalf of residents and administered to them by the care staff was stored in a locked, vented cupboard in the hallway next to the St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 13 manager’s office. Medication due to be returned to the pharmacy was locked in a separate facility within the cupboard. These were entered in the returned drug book when they were collected for return. There were no controlled drugs prescribed for the people living at the home. The Medication Administration Records (MARs) had many gaps in recording for the administration of eye drops and medication. This means it was not possible always to be certain if people had their eye drops given to them or not. One person’s MAR indicated that some Paracetamol tablets had been carried forward from the previous month however this information was not signed or dated to indicate the staff member responsible for this task or when it had been undertaken. One person’s MAR did not include a photograph of the person. There were initials crossed out on the MARs so it was not always possible to confirm if people had received their medication or identify who had administered it. The registered manager and deputy signed a sheet at the front of the medication book daily to confirm they had checked that the MAR sheets had been correctly completed. Medication prescribed to be taken as required such as Paracetamol and CoDydramol were not accurately recorded for the time they were given to people. Record sheets indicated 0900hrs and 1200hrs. This would indicate that these tablets were being given to residents too close together. The registered manager responded that the recording was not accurate because the medication rounds were undertaken at 08:30hrs at Breakfast and 12:30hrs at Lunch, providing the appropriate time lapse of 4 hours between doses. It was noted that these medications were prescribed as ‘when required’ however they were routinely given to people at ‘medication rounds’ as opposed to a person centred regime. It was reported that GPs visited the people living at the home ‘ad hoc’ to undertake medication reviews. We did not see evidence of this at this visit and there was no system in place to monitor this practice to ensure people had a regular check of their medication regime. People living at the home confirmed they felt they were looked after with dignity and respect. One person told us “I always get support when I need assistance and this I am so grateful for” However, as reported under the Environment outcome section of this report it sometimes took 3 staff members to help people in and out of the bath due to a faulty bath seat. This practice did not respect the dignity of the person being bathed. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 14 People living at the home had access to a telephone in a small booth in the communal hallway. On the day of this visit it was noted that a heavy armchair was positioned in front of this booth making access difficult and a vacuum cleaner was stored within the booth potentially causing a hazard for residents who may be unsteady on their feet. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to enjoy a lifestyle that meets some of their expectations such as having visitors and enjoying good food. Other aspects of daily life such as activity and occupation may be less suited to meeting their individual needs. EVIDENCE: The home’s Service User Guide stated there were regular residents’ meetings where activities were discussed. The manager told us that residents’ meetings had not been effective, as people did not ‘speak up’ in a large group. Instead there were smaller and more intimate coffee mornings held where people were encouraged to make suggestions relating to activities and daily life at St. Catharines. A singer attended the home on the day of this visit to entertain the residents and invite them to sing along with him. He was heard interacting with people in a positive way discussing topical events in the show business world. Residents were not able to give us examples of group activities they enjoyed, individuals said “I do embroidery and crosswords” and another said, “I do embroidery and reading”. There was a weekly church service held in house on Wednesdays. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 16 Surveys were received from residents, relatives and staff as part of this inspection. Under the section How do you think the care home can improve? Were comments such as “Maybe organise more trips out for the residents, as was the case in previous years.” And “A few more activities and an exercise class again would be nice”. The gardens at St. Catharines were beautiful with areas for people to sit and enjoy colourful and aromatic plants. Some people told us they wished they could go out into the garden more but there were not often enough staff to allow this to happen. The manager reported that the routines of daily living were flexible and that people were not restricted regarding what time they went to bed and what time they rose, it was the choice of the individual. Residents we spoke with said they felt they were ‘supposed’ to go to bed and get up when staff suggested it; it appeared to us that people had forgotten how to exercise choice over these daily activities. It was reported that breakfast was served at 08:30hrs and most people come down to the dining room for this meal. A supper (Hot drink and a bite to eat) was served at 8pm and most residents retired to bed after that. The visitors’ book showed us that people had regular visits from friends, relatives and representatives. The home had a hairdressing salon, one of the care staff team is also a hairdresser and the salon was manned 2 to 3 days per week depending on requirements. People spoken with said they appreciated being able to look their best when their families visited them and that a nice ‘hairdo’ made them feel good about themselves. There were menus displayed in picture frames by the dining room door, these were in quite small print, residents spoken with said they were not aware they were there. Sample menus in the Service User Guide indicated that the service provides daily choices for lunch and supper such as Shepherds’ pie or omelettes and baked beans on toast or soup and sandwiches. However the copies of menus we brought away from the home and discussion with residents told us that this was not the case, there was one lunch option and one supper dish offered. People said they didn’t have a daily choice but if they didn’t like anything the cook would always do something extra. One person told us they didn’t want fish and chips on Friday, so the cook prepared egg and chips for this person. People spoken with after lunch on this day said, “Lunch was very good, tasty” and “If you really don’t like what is offered they will make you something else”. Food stocks were noted to be of good quality with fresh fruit and vegetables available. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 17 The manager reported that the menus are sometimes wavered from when residents indicated that they were bored with the daily options; the current menu was there for guidance only. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People will be able to raise concerns about the service however; the lack of recording systems may mean that some issues may be overlooked. They can expect to be safeguarded from abuse by good procedures being in place and staff having a sound knowledge of these. EVIDENCE: The service had a complaints policy and procedure in place. We noted this was not included within the Service Users Guide. The service had no system of logging complaints in order to identify trends and patterns. The manager reported very few issues arising at the home; examples given were of missing teeth, hearing aids and glasses etc. but that the ethos of the home was such that these were not perceived to be complaints because they were dealt with immediately. Discussion was held about training staff members to recognise what is a complaint and to log the perceived ’minor’ issues. Discussion was held around how this could feed into the home’s quality assurance system. One complaint received by the home and the commission since the previous inspection visit was deemed by the service to be unsubstantiated. The manager reported that Head Office had dealt with the complaint therefore the paperwork relating to the investigation was not available in the home for inspection at this visit. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 19 Surveys received from residents and families included comments, “I hope I never have to make a complaint for St. Catharines has full marks in my eyes” and “There is a complaints forms on display at St Catharines” and “Never had any reason to make a complaint!” A training matrix was not available at the time of the visit to confirm what training staff members had attended. However the manager was able to tell us subsequent to this inspection site visit that 7 of the 23 staff members had not received up to date Adult Safeguarding training and they were booked to attend training this month. The manager obtained enhanced Criminal Record Bureau checks for all new staff before they commenced working at the home. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a clean and comfortable environment however slow responses to necessary repairs and maintenance can impact on their safety and dignity. EVIDENCE: As part of this inspection site visit we took a complete tour of the home, it was clean, tidy and fresh. One completed survey included the comment “This is the first care home I have ever been in, the cleanliness is the best, the beds are always sweet and fresh so I never feel unclean because everything is there for us to use. Full marks to the home for the care we receive”. The home had three double bedrooms, two of which were under single occupancy. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 21 In the bathroom on the ground floor the assisted bath seat had failed and an alternative had been supplied however this was not suitable for purpose and did not function. Care staff reported that it sometimes took 3 staff members to help people in and out of the bath. Not only is this not appropriate as the room is very small but it doesn’t respect the dignity of the person being bathed. A shower chair in 1st floor shower did not lock into position either when swung outwards to allow someone to get in or out of the shower or when swung inwards when the shower was in use. The chair was an integral part of the shower unit and as such couldn’t be replaced for another. Where the chair was attached to pivot the mechanism was corroding and dirty. The manager reported that repairs or general maintenance requests were reported via fax to the group Head Office. The manager was not able to demonstrate that the aforementioned issues with the bath chair or shower chair had been raised with Head Office. Infection control training has been delivered to 19 of the 23 staff members. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to be supported by sufficient numbers of staff who have a good level of basic training. People can be confident they will be cared for by a team of well-recruited staff. EVIDENCE: Staff rotas confirmed that three care staff members were on duty for day shifts and two care staff members were on duty for waking night shifts. Surveys completed by residents as part of this inspection process included comments such as “There is always staff ready to help and listen if one feels below par, they have always been kind to me” and “We have some really nice carers; they always do their best to make us feel at home”. Ten of the twenty three staff employed to work at St. Catharines had achieved minimum NVQ level 2 qualification in care. This did not meet the recommended ratio of 50 of the staff team achieving this level of qualification. We looked at two staff recruitment files to confirm all the necessary checks were made when new staff members were employed to work at the home. This was to ensure the right people were safely recruited to look after the people living at the home. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 23 Written application forms were completed, these did not include accurate dates for any positions held prior to this appointment. Eg 1991 to 1995 is not sufficient to identify any gaps in employment history. The service needs to be confident that any gaps in employment history are explored with the applicant at interview. Staff files included a record of the questions asked at interview however there was no record of the applicant’s responses to these questions. There was evidence to confirm that two written references and an enhanced Criminal Record Bureau were obtained before staff started to work at the home. The organisation had started to introduce induction training in line with Skills for Care. Currently the induction programme included basic core training elements such as moving and handling, safeguarding vulnerable adults, health and safety and fire safety. The manager was able to provide evidence subsequent to this inspection visit that staff members attended regular training updates to ensure their skills and knowledge were suitable to meet peoples’ personal care needs. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home that is generally well managed. EVIDENCE: The manager had been in post for three years and registered with the commission for two years and had achieved the Registered Manager’s Award and NVQ level 3. She had undertaken all core refresher training alongside the staff team including food hygiene, Health and safety and some management training. The provider organisation had a system for quality assurance within all homes in the group involving surveying the views and opinions of people living at the home, staff members, relatives, healthcare professionals and any other external stakeholders in the service. The registered manager reported that St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 25 she audited the responses to the surveys and produced an action plan to meet any identified shortfalls in the service provision. This years Quality Assurance exercise was due to be undertaken in September 2008 to allow people some respite because the commission’s surveys had been sent out in June and there was a risk of people becoming weary and lethargic about responding to surveys. The service did not keep any monies on behalf of 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. The home had all the necessary policies and procedures in place to help keep people safe. The manager provided us with information subsequent to this visit to confirm that the staff training programme included the necessary training to promote the health safety and welfare of the people living at St. Catharines. This included moving and handling, fire safety, health and safety, infection control and safeguarding vulnerable adults. Requests for repairs and maintenance were forwarded to head Office; the registered manager reported that these were usually dealt with promptly. However there were outstanding issues with the down stairs bath chair and the 1st floor shower chair that had a negative impact on the potential safety of people using these facilities. St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 26 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 27 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. 1 Standard OP1 Regulation 4 Requirement The Statement of Purpose must be updated to accurately reflect the services and facilities available at the home so that people can make an informed choice. Timescale for action 31/08/08 2 3 OP9 OP7 13(2) 15 Medication administration must 31/08/08 be accurately recorded to protect people from the risk of harm. The person in charge needs to 31/08/08 ensure that daily records are sufficiently detailed to help ensure a consistent approach and good quality of care for people living at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 28 St Catharines Residential Home DS0000019536.V369087.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V369087.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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