Inspection on 17/01/06 for St Catherine`s Care Home

This inspection was carried out on 17th January 2006.

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

The inspector 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 Catherine`s Care Home 11/11/08

St Catherine`s Care Home 22/11/06

St Catherine`s Care Home 31/08/05

St Catherine`s Care Home 07/02/05

St Catherine`s Care Home 09/08/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Catherine`s Care Home West Road Newcastle Upon Tyne NE15 7PY Lead Inspector Deborah Haugh Announced Inspection 17th January 2006 09:30 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 Catherine`s Care Home DS0000041216.V262858.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 Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Catherine`s Care Home Address West Road Newcastle Upon Tyne NE15 7PY 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) 0191 2452400 stcatherines@stcuthbertscare.org.uk St Cuthberts Care Miss Judith Anne Harding Care Home 45 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (36) of places St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/08/05 Brief Description of the Service: St Catherines Care Home is purpose built and provides nursing,personal and social care,and also provides 9 Dementia care beds for older people. The home is situated on the West Road in Newcastle upon Tyne and is part of St Cuthberts Care. The home is accessible to all local amenities and public transport. All the accomodation is at ground level and there are extensive gardens and there is ample car parking. There are 45 single en-suite bedrooms,six of which could be used as companion rooms.Several of the bedrooms have patio doors which lead into the internal secure garden. There are several communal lounges and two dining rooms.There is a conservatory,Chapel and quiet room. There are bathrooms, a shower room and toilets close to all resident areas. All of the facilities caters for those with disabilities. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on 17/01/06 from 9.30 until 4.30pm. The Registered Manager, Miss Judith Harding was on duty during the visit. There were 43 service users at the time of the visit. Staffing levels were checked. Time was spent looking around the home to check the cleanliness, maintenance and decoration during the visit. Prior to the inspection questionnaires were provided to service users and relatives. Service users completed eight questionnaires. Relatives and visitors completed twenty-six questionnaires. Service users and visitors shared their views during the inspection. Time was also spent observing the contact between the service users and staff. Five care plans were examined. Arrangements for the administration and management of medication were checked, recruitment NVQ training, finances, catering and quality assurance were also examined. What the service does well: Comments from service users included; - ‘Nothing wrong here. Visited other places nothing like this.’ - ‘ Staff are excellent, there aren’t any bad carers here.’ - ‘Lunch was lovely.’ ‘Get a choice of food.’ - ‘Top of the world.’ - ‘Very happy here.’ - ‘Comfortable here.’ - ‘Staff are very good.’ - ‘Matron has sorted things out (in the past).’ -‘Well run home. Safe and with every amenity you could wish to have. Staff are excellent, carers are well named as they look after us so well. Carers are supportive when the need arises. Advise is given when asked.’ - ‘St Catherine’s is a friendly place, always looking to make it as near to home as possible. I am glad I came to live here.’ - ‘The cook is excellent.’ Seven questionnaires felt that suitable activities were provided and 1 said ‘sometimes.’ Seven questionnaires said they felt safe and 1 queried the night shift cover (Staffing at night are as agreed see NMS 27) Comments from relative/visitors questionnaires included; St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 6 - ‘I can’t speak too highly of the care X is receiving.’ - ‘Staff are always helpful and caring. They do a demanding job.’ - ‘X always looks happy and well cared for.’ - ‘The standard of cleanliness and care is excellent.’ - ‘The staff are always most helpful and attentive.’ - ‘High turnover of staff (2 views), quality of food varies considerably.’ - ‘Well run, kind carers.’ - ‘Never had a problem that wasn’t fixed.’ - ‘St Catherine’s staff are always courteous to X and family. Their care and concern is exceptional and I would have no hesitation in recommending the home to anyone.’ - ‘Staff are caring and compassionate and seem to have genuine affection for those in their care.’ - ‘Sometimes feel that there are not enough staff.’ (14 people said yes there were enough staff, 8 people said no and 1 person said ‘not always’.) - ‘They (staff) do not have an easy job but they never complain. They have more than their quota of staff set down in government guidelines. Most patients need one-to-one – so they should have more staff.’ - ‘Difficulty to get it answered.’ (Telephone to speak to relative.) - ‘The care to all the residents is good.’ - ‘Very happy with the standard of care, the staff and the building.’ - ‘Tea (drink) is like dish water - very weak and tepid.’ 26 questionnaires indicated that relatives were consulted about their care if the service user was not able to make decisions. 26 questionnaires indicated that relatives could visit in private. Catering arrangements are good in relation to special dietary needs, care plans are in place and the kitchen has the information required including people’s preferences. The cleanliness of the home and infection control measures are satisfactory. 51 of care staff are trained to a minimum of NVQ Level 2, which exceeds the standard. The standard required is 50 by 2005. The Registered Manager has completed the Registered Managers Qualification. A continual programme of decoration is in place and the dining room next to the kitchen will be decorated. Staffing is at the agreed levels. What has improved since the last inspection? St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 7 The requirements made at the last inspection have been addressed in relation to care plans, medication, safety concerns regarding items on wardrobes and improvements to the courtyard. 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 Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 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 Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3 was assessed and met at the last inspection, NMS 6 is not applicable. EVIDENCE: St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 There is consistent care planning in place, which provides staff with the information they need to ensure service users individual care needs are met. The health needs of service users are met with evidence of multi disciplinary working taking place. But one area requires addressing. The systems for the administration of medication are appropriate and protect service users. Service users are treated with dignity and their privacy respected but one area needs addressing. EVIDENCE: 7 & 8) Five care plans were examined and assessments such as nutrition, pressure area prevention, continence, mental health, dependency, falls and moving and handling are in place. Care plans are identified to meet particular needs. The guidance is clear and these are evaluated each month. The use of ‘lap straps’ with service users was observed during the visit and documentation was examined. Risk assessments have been identified in four plans and relative’s permission has been sought. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 11 ‘Lap straps’ and other restraint equipment may be appropriate equipment to provide someone with more stability and support to prevent rolling out, tipping and sliding out. It is recognised that dilemmas exist to keep service users safe and prevent falls. Evidence of multi-disciplinary involvement must be in place. This was not found in the home. The home has sensors in place for some service users regarding fall prevention where an alarm is sounded should a person get out of bed or up from a chair. A copy of The Royal College of Nursing ‘Restraint revisited – rights, risk and responsibility.’ Guidance for Nursing Staff 2004 was provided to the home following the inspection. All service users have access to all NHS facilities. They are registered with local GP services and have regular visits from opticians, chiropodists and dentists. The district nursing service provides the nursing care for the service users not receiving nursing care. Evidence from the care plans show that advice is sought and acted upon regarding prevention of pressure damage, wound care, continence care and nutrition. The home has specialist pressure relieving equipment and further equipment can be sourced as necessary. 9) The requirements regarding medication have been addressed and daily temperature checks are recorded for the treatment room, an up to date British National Formulary, which gives details regarding all medicines, dosage and side effects is available. Directions for medication are clearer and GP’s have been approached for more detail. The arrangements for the disposal of controlled drugs are being dealt with. Discussions with ALCO and Boots are in hand. A full audit was completed at the last inspection. 10) Service users are able to have their own telephone in their bedrooms. All the rooms have a telephone point. People are addressed by their preferred name and this is recorded in the care records. Personal care is provided in private. The laundry was inspected and a large bag of un-named hosiery was found. Normally the laundry staff attach name tags to hosiery. The Manager is strongly recommended to provide individual delicate bags for hosiery to prevent the potential for communal shared clothing. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 & 15 (NMS 12 was assessed and met at the last inspection.) Service users are able to maintain relationships, which are important to them. Service users are supported to exercise their choices and autonomy. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices as well as special dietary needs. EVIDENCE: 13) Service users and relatives/visitors views indicate that they are able to visit when they wish and people are able to meet in private. Service users only see people they wish to see. One service user indicated a wish to visit a market and the Registered Manager said she would accommodate this. 14) Where able service users are supported to handle their own affairs. Information is provided on the homes notice board to contact advocacy services where required. People were observed to be surrounded by their own possessions and keepsakes in their bedrooms. 15) The home has a new chef and reviewed menus are to be introduced 23/01/06. The kitchen assistant explained the arrangements for meeting service users special dietary needs. A record of each person’s needs and preferences are identified. Good documentation is in place. St Catherine`s Care Home DS0000041216.V262858.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): 18 (NMS 16 was assessed and met at the last inspection) Arrangements are in place to ensure staff have knowledge of Adult Protection issues, which protect residents from possible harm or abuse. However the use of restraint must be reviewed. EVIDENCE: The arrangements for the protection of vulnerable adults was assessed and met at the last inspection. There are comprehensive policies available to ensure staff follow the steps to take should there be any allegation or suspicion of abuse. The concerns raised regarding the use of ‘lap straps’ must be reviewed (See NMS 7 & 8). St Catherine`s Care Home DS0000041216.V262858.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 & 26 The standard of the environment is good providing service users with an attractive, clean and comfortable place to live. EVIDENCE: The location and layout of the home is suitable for the needs of the service users. All areas were found to be well maintained and extremely comfortable. Service users can access the grounds, which include a safe secure grass area and central courtyard. There are various communal areas including a Chapel, two dining rooms, lounges, quiet rooms, smoking room and conservatory for service users to use as they wish. The dining room next to the kitchen is planned to be redecorated as it is showing the effects of wear and tear. There is an on-going programme of redecoration. All areas were found to be homely and tastefully decorated and furnished. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 15 All of the bedrooms are single and have en-suite facilities. Six of the bedrooms could be used as companion rooms if necessary. Several of the bedrooms have external patio doors, which lead directly into the central garden area. Bedrooms are personalised and people are able to bring their own possessions and keepsakes. Specialist profile beds are provided for service users receiving nursing care. All of the bedrooms are furnished and fitted to a high standard. There are five assisted bathrooms and one shower room. All facilities are close to lounges and dining rooms and are accessible to those with disabilities. Three toilet locks were broken but were being fixed. The home has suitable infection control procedures in place, which were being followed by all staff. The inspector spoke with the laundry assistant and domestic regarding cleaning and laundry arrangements. Quality checks are in place for bedrooms and house keeping. The laundry is well equipped, clean and organised and there are suitable separate sluicing facilities. (See NMS 10) Hand washing facilities are available throughout the home including en-suite areas. The home was clean, tidy and free from any unpleasant odour. St Catherine`s Care Home DS0000041216.V262858.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, 28 & 29 (NMS 30 was assessed and met at the last inspection) The home is suitably staffed with qualified nurses and care staff at agreed levels. Service users are protected from potential harm as robust recruitment systems are in place. Service users are cared for by staff that are trained and competent. EVIDENCE: 27) The staffing rota was checked over a 4 -week period and on the day. Staffing was found to meet the required levels. The home continues to staff the home as follows: 1 1st Level General Nurse throughout 24 hours. 9 care staff in the morning one of which finishes at 11.00am. 7 care staff in the afternoon and evening 4 care staff overnight. A senior carer is included in these numbers. The home has a designated activities person, domestic and laundry staff employed over 7 days, separate chefs, kitchen assistants and an administrator. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 17 There is a Registered Manager in post and a General Manager is also employed. Agency staff are deployed to cover any shortfalls in staffing. 28) The home has 51 of care staff with a minimum qualification of NVQ Level 2 or above which is commendable. 29) Recruitment checks of Criminal Records Bureau (CRB) certificates of 19 staff were made and are in place. The Deputy Director confirmed that CRB certificates will be retained in keeping with CSCI 11th November 2005 Guidance - www.csci.org.uk St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 On the whole the home is well run with service users wishes and needs being met. Quality assurance systems are in place, which ensure that the service provided to service users is suitable. Arrangements for the management of service users own personal money protects service users. Health and safety arrangements protect service users. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 19 EVIDENCE: 31) Registered Manager has completed her D32 NVQ assessor award and the Registered Managers Qualification. 33) The Inspector was informed following the inspection that St Cuthbert’s Care has a quality assurance system. A monthly visit (both announced and unannounced) is completed by the Risk Manager. A report is completed and discussed at St Cuthbert’s Care Risk Panel Meeting. The Panel meets every 46 weeks; and comprises of members of senior management team including the Director. Action plans are agreed where applicable. Care Reports from all of the services are requested on a monthly basis and looked at where necessary at the Risk Panel. Views of service users and families are sought via service evaluation forms sent out on a 6 monthly basis. Regular service user and relatives meetings are held. 35) Service users money, which is looked after by the home, is securely stored. Only the Registered Manager, Deputy and Administrator have access. Audit checks are made each month but a record of this is not made. Balances were checked in the presence of the Registered Manager. Valuables, which are being looked after by the home, are recorded on one sheet. 38) The courtyard area has been made safe with suitable paving. Large personal items stored on tops of service users wardrobes, which could cause a toppling incident or accident have been removed. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 21 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 OP8OP7OP 18 Regulation 13(7) Requirement The use of ‘lap straps’ must be re-assessed immediately via multi-disciplinary involvement and where appropriate the use must be clearly documented, reviewed for all identified service users and thereafter. Timescale for action 17/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP35 OP10 Good Practice Recommendations Consider providing a valuables record per service user (not on one record) and record when audit checks are made. Introduce the use of delicate bags for hosiery. St Catherine`s Care Home DS0000041216.V262858.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Catherine`s Care Home DS0000041216.V262858.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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