Inspection on 31/08/05 for St Catherine`s Care Home

This inspection was carried out on 31st August 2005.

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

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

Other inspections for this house

St Catherine`s Care Home 11/11/08

St Catherine`s Care Home 22/11/06

St Catherine`s Care Home 17/01/06

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 Catherines Care Home West Road Newcastle upon Tyne Tyne and Wear NE15 7PY Lead Inspector Irene Bowater Unannounced 31 August 2005 09:15 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 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 Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Catherines Care Home Address West Road Newcastle upon Tyne Tyne and Wear NE15 7PY 0191 245 2400 N/A stcatherines@stcuthbertscare.org.uk St Cuthberts Care Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Judith Anne Harding CRH 45 Category(ies) of DE(E) - Dementia - over 65 (9) registration, with number OP - Old Age (36) of places St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th February 2005 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 Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 6 hours. The registered manager was available and assisted throughout the day. Ten staff, eleven residents, and three visitors were spoken to throughout the day. Part of the day was spent in the office examining records and the majority of the time was spent touring the home and spending time with residents and staff. What the service does well: What has improved since the last inspection? Since the last inspection the use of agency staff has decreased in the home. The staff are more consistent and have formed a stable staff team who are keen to develop the service. The choices and nutritional content of all meals has improved and residents all said they enjoy their food and can have anything they want. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 6 The requirements from the last inspection have been met or are currently being addressed. There has been some further landscaping of the gardens and another fence has been erected to ensure resident safety. 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 Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,5 The admission procedures are comprehensive and ensure the staff can meet residents assessed needs. Preadmission visits enable residents and their representatives an opportunity to assess all aspects of the service before they decide to move into the home. EVIDENCE: The home has detailed preadmission assessment records, which are completed before residents move into the home. The home also receives a comprehensive care plan from Care Managers and from these assessments the residents care plan is formulated. The home encourages potential residents and their representatives to visit the home before moving into the home. Residents have six-week trial followed by multi disciplinary review before deciding to stay in the home on a permanent basis. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There is no consistent care planning in place to adequately provide staff with the information they need to ensure residents individual care needs are met. The health needs of residents are met with evidence of multi disciplinary working taking place. The systems for recording of medicines are not satisfactory which may place residents at risk. The staff have a good understanding of the residents support needs, which ensures residents’ privacy, rights and independence are protected. EVIDENCE: Each resident has a plan of care based on the admission assessments. Six care plans were inspected and the recording varied in all of them. The original care plans were competed to a good standard, however they had not been updated for some considerable time and did not reflect the current needs of the residents. The assessment tools including, dependency, nutritional status, Waterlow scoring, weights and risk assessments were not up to date. The care plans St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 10 were not being reviewed monthly and the staff would not be able to follow the care that needs to be given to individual residents as their needs change. All events are comprehensively recorded in the daily progress notes, which are kept separately from the care plans. The manager confirmed that changes to the care planning process are currently underway. All residents 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 residents 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. There are policies in place for staff to follow to ensure the safe administration of medicines. The requirements from the last inspection have been actioned. The nursing and senior care staff have been trained and they administer all medication in the home. The records were generally well kept, although some directions on the Medicine Administration Records were not written out in full. An audit of the Controlled Drugs and check of the Controlled Drug register was satisfactory. One Controlled Drug, which is no longer required, should be returned to the Pharmacist. Despite a ventilation system and an electric fan, the room remains very warm. The British National Formulary, which gives details regarding all medicines, dosage and side effects, was out of date. All of the staff were observed to knock on doors and wait for a reply before entering and all care was carried out in private. The residents spoken to were without exception complimentary about the staff and how they ensure all their needs are met. Comments from them included St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 11 “they are the best”, “the staff always help me” and “I am well cared for”. The residents and staff have formed good relationships with the interaction being professional and based on mutual regard. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 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 standard(s) 12,15 Social activities are well organised and provide stimulation and interest for the residents’ living in the home. Dietary needs of residents are well catered for with a balance and varied selection of food available that meets residents’ taste, preferences and specialist needs. EVIDENCE: The home benefits from having a varied, organised activities programme .All events that are arranged are displayed in the home and records of individual activities are recorded. A relative produces a monthly newsletter for the residents, which is full of interesting information about the daily life and activities in the home. On the day of the inspection the residents were enjoying a planned “keep fit” programme and on the afternoon a weekly visit from the “pat a dog”. Other events include outings to the garden centre, Harry Ramsdens’ for a sing a long and fish and chips and visits to the Playhouse. In house entertainment includes evening entertainment, board games pie and pea suppers. Several of the residents enjoyed watching the Tall Ships leave the Tyne. The residents spoken with said, “the entertainer was good, we enjoyed it”, “the St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 13 visit to the playhouse was very good and we have another visit planned”, and “there is always plenty to do if you want to join in”. The home has a menu, which offers choice and variety for all meals. Since the last inspection the home has worked hard to provide nutritious wholesome food and is still developing this service. The head chef is to commence a training course regarding diets and nutrition. On the day of inspection the residents were offered choices for both the main meal and dessert at lunchtime. All the meals are plated in the kitchen and were of ample portion size and were nicely presented. A choice of cold drinks was offered throughout the meal and staff gave assistance to residents in a sensitive unhurried manner. Hot and cold drinks were available throughout the day and fortified drinks are made in the kitchen and are also readily available. All of the residents were complimentary about the meals provided saying “there is always plenty to eat”, “I always get what I want”, and the “food is lovely”. The kitchen was clean and well organised. The fridge, freezer and core food temperatures were recorded and the kitchen has a cleaning schedule. There was a varied range of frozen, fresh, tinned and dried food available and the cooks were busy preparing home baked cakes for later in the day. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a satisfactory complaints system in place with evidence that residents’ feel their views are listened to and acted upon. Arrangements are in place to ensure staff have knowledge of Adult Protection issues, which protect residents from possible harm or abuse. EVIDENCE: The home has comprehensive policies available which set out how and to whom complaints may be made. The procedures are readily available and residents’ said they would be able to use the procedure and were sure that the staff would deal with any problems they may have. The records show that five complaints have been recorded and resolved at home level. The Company deals with formal complaints and these records are held in their offices. There are comprehensive policies available to ensure staff follow the steps to take should there be any allegation or suspicion of abuse. One Protection of Vulnerable Adults investigation has taken place since the last inspection. The home followed Local Authority Procedural Frameworks and their own procedures to ensure protection of residents. Staff have received training in Protection of Vulnerable Adults, Challenging behaviours and dealing with physical restraint. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,24,26 The standard of the environment is good providing residents with an attractive, clean and comfortable place to live. EVIDENCE: The location and layout of the home is suitable for the needs of the residents. All areas were found to be well maintained and extremely comfortable. Residents can access the grounds, which now has a secure fence, and are being landscaped as part of an ongoing programme. There are various communal areas including a Chapel, two dining rooms, lounges, quiet rooms, smoking room and conservatory for residents to use as they wish. All of the areas presented extremely well and are tastefully decorated and furnished. All of the bedrooms have en-suite facilities which one resident said was “the best part of her room”. There are five assisted bathrooms and one shower room. All facilities are close St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 16 to lounges and dining rooms and are accessible to those with disabilities All of the requirements from the last inspection have been resolved. 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. Specialist profile beds are provided for residents receiving nursing care. All of the bedrooms are furnished and fitted to a high standard. The residents have been encouraged to bring small items with them making their rooms highly individualised and reflecting individual lifestyles and preferences. The home has suitable infection control procedures in place, which were being followed by all staff. The laundry is well equipped, clean and organised and there are suitable separate sluicing facilities. Hand washing facilities are available throughout the home including en-suite areas. The domestic staff work extremely hard to provide a clean, tidy home, which is free from any odour. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home is suitably staffed with qualified nurses and care staff to ensure their needs are met. The recruitment processes are followed which protects residents from harm. The induction and training of staff ensures there is consistent care provided by trained competent staff. EVIDENCE: The home has experienced recruitment difficulties for both care and qualified staff. The problems are being addressed which is resulting in a stable consistent workforce. Agency staff are deployed to cover any shortfalls in staffing. 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. There is a registered manager in post and a general manager is also employed. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 18 A random check of staff files found that the home follows the recruitment procedures. Files showed evidence of 2 references, Criminal Record Bureau checks, proof of identity, proof of qualifications and terms and conditions of employment. The home has a training and development programme in place. The staff confirmed that there was always training available for them. Two new members of staff are enrolled on a Care Assistants training course based at the General Hospital. These are new staff who have already completed full induction training and have been working along side experienced staff for two weeks. Other training includes all mandatory training and specialist training to meet residents assessed needs. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,36,38 The management approach provides clear leadership and direction with staff demonstrating knowledge of their roles and responsibilities to ensure residents receive consistent quality care. There are some health and safety issues, which have the potential to pose risks to residents. EVIDENCE: All the residents and staff spoken to were complimentary about the management style in the home. They said that the manager was always available and would discuss and issue that they had. There are regular resident and staff meetings held and minutes of all meetings are available in the home. Since the last inspection staff said they are confident, organised and feel part of a team who work well together. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 20 The staff have formal supervision six times a year. They are also supervised and directed on a daily basis by the manager and the senior staff team. The supervision covers all areas of practice and career development needs. Health and safety policies and procedures are in place for staff to follow. The records show that staff receives training in first aid, fire, infection control, food hygiene and moving and assisting. The fire records and fire risk assessment were completed to a satisfactory standard. Accidents and incidents are recorded and monthly analysis carried out. Risk assessments for all safe working practices are available. Regular maintenance and safety checks are carried out with records kept. The last inspection identified that the gravel flooring was a tripping and slipping hazard for residents with cognitive, sensory or mobility impairments, the home is in the process of replacing the gravel with suitable paving. Many of the residents have large personal items stored on tops of their wardrobes, which could cause a toppling incident or accident. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 x x x 3 x 2 St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 7 Regulation 13,15 Requirement The care plans must set out in detail the action which needs to be taken by staff to ensure that all aspects of the health,social and personal care needs of residents is met. The residents care plan must be reviewed at least once a month,updated to reflect changing needs and current objectives for health and personal care. All directions on the Medicine Administration Record must be clear and written out in full. The room temperature must be recorded daily to ensure correct storage of below 25 C is maintained. The discontinued Controlled Drug must be returned to pharmacy. The home must provide an up to date BNF. The home must continue to replace the gravelled area in the courtyard. Personal items must not be stored on tops of wardrobes as this poses a toppling risk Timescale for action 31st October 2005 2. OP 9 12,13 31st October 2005 3. OP 38 12,13 31st October 2005 St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 23 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 OP 31 OP 38 Good Practice Recommendations The registered manager should progress with the Registered Managers Award. The home should continue with the plan to landscape the garden areas to provide a safe environment for residents to use. St Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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 Catherines Care Home B53-B03 S41216 St Catherines V237655 310805 Stage 4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!