Inspection on 21/06/07 for St Catherine`s Home

This inspection was carried out on 21st June 2007.

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 Home 14/10/08

St Catherine`s Home 19/06/06

St Catherine`s Home 03/10/05

St Catherine`s Home 04/04/05

St Catherine`s Home 08/11/04

St Catherine`s Home 13/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Catherine`s Home 35 Derby Road Enfield Middlesex EN3 4AJ Lead Inspector Stephen Boyd Key Unannounced Inspection 24th May 2007 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 Home DS0000059522.V336690.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 Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherine`s Home Address 35 Derby Road Enfield Middlesex EN3 4AJ 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) 020 8804 1136 020 8804 1136 ADR Care Homes Ltd ** Post Vacant *** Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16) of places St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The four service user places for those with dementia are restricted to the ground floor accommodation only. 19th June 2006 Date of last inspection Brief Description of the Service: St Catherines Home is a care home for sixteen older people of either gender who are in need of personal care only. The home is a large detached house in Enfield, which was extended and opened in 1986. There are shops and bus and rail routes a short distance away. The home has twelve single bedrooms and two double bedrooms on the ground and first floor. A lift is available to access both floors. On the ground floor there is a good size kitchen, a large through lounge and a dining room. At the front of the home, there is off street parking for several vehicles and to the rear, there is a large well-kept garden with two large sheds. The fee range for residents living in the home is £398 - £420 per week depending on their needs. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in one day in June 2007. I met with the proposed manager. Discussions took place with three people living in the home in private and others in general. Three staff were also spoken with. A tour of the premises both internal and external took place and various records, policies and procedures were viewed. What the service does well: What has improved since the last inspection? What they could do better: This inspection has highlighted seven new requirements that need to be addressed to enhance the quality of care for people living at the home. A record of complaints must be kept and any complaints received must be recorded with actions taken and outcomes noted. All staff must receive training in relation to the protection of vulnerable adults and training certificates should denote what has been covered. The premises must be improved in line with the details given under standard Nineteen of this report; this includes for example, some new armchairs for the lounge and the purchase of an assisted bath. An application must be made to the CSCI for the registration of the proposed manager. Further work need to be undertaken in respect of the homes quality assurance processes. Financial records relating to people living at the home must show receipts for all items purchased on their behalf. An up to date. Electrical installation safety certificate must be available for inspection St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 6 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 Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are assessed prior to being admitted to determine that their needs can be met. EVIDENCE: Assessments were seen to have been carried out in respect of people living at the home. These were seen to be comprehensive, taking a holistic approach to peoples needs. People spoken with during the inspection although not always recalling that they had an assessment, said that they were made to feel very welcome when moving to the home. The home has an admission policy that details what the arrangements are for people moving to the home. The home does not offer an intermediate care service. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have individual plans of care. The health care of people is given a good level of priority. The homes’ medication procedures are appropriately put into practice. People living at the home have their rights respected. EVIDENCE: Plans of care were in place for people living at the home. They were reviewed regularly and related well to people’s ongoing needs. A recommendation is that plans also incorporate an “goal” approach whereby people can work towards small improvements for example, more involvement in social activities if they want and would benefit from this approach. A key worker system is in operation, which helps to individualise the care experience for people at the home. People’s health care needs are seen as an integral part of their overall care. They are identified in care plans and evidence of appointments with various St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 10 health professionals such as G.P’s, chiropodists, dentists and opticians were recorded in peoples care files. People said that they could see health professionals when they wished and in private if that was what they wanted. The home operates a monitored dosage system of medication. This was viewed at the inspection and found to be working appropriately. Medicines are held securely and problems encountered at the previous inspection relating to signing and coding of any non-administered medication had been resolved. Staff have received training in medication administration, uses and side effects. People spoken with during the inspection said their medicines were always given at the correct times. People spoken to during the inspection said they were well treated and cared for by staff. Staff were observed to interact well with people in a courteous and friendly way. People said they were not subject to rigid routines such as having to go to bed at set times or being told what to eat or wear. People looked well cared for during the inspection. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home enjoy a range of activities. Contact with families and friends is an integral part of peoples social experience at the home. People can exercise choice in their lives. People have a varied diet and can eat meals in pleasant surroundings. EVIDENCE: A range of social activities are available to people living at the home. On the day of the inspection Bingo was an organised activity. Other activities, which take place, include: Music sessions, skittles and ball games. People enjoy watching television and reading magazines. Trips out to shops and local parks take place. People are able to follow their religious beliefs and a minister comes to the home periodically to give communion to two people. All of the people living at the home have contact with family and or friends to varying degrees. People spoken with said they can receive visitors to the home and that they are made to feel welcome. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 12 Meetings for people living at the home are held every couple of months and minutes of these were seen. People confirmed they can attend these meetings and have their views and opinions listened to and acted upon. In day-to-day living people can exercise choice and control over what they do and when they do it. For example, whether to join in activities and where to sit in the lounge. People spoke well of the food on offer at the home, both in terms of quantity and quality Menus were seen which offer a choice of meals. Alternatives to the choices on offer can be given at peoples request. The lunchtime meal on the day of the inspection looked appetizing and was well presented. People said they had access to a range of drinks and had drinks regularly throughout the day. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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. 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. The home needs to ensure there is a method of recording complaints. Some staff need to undergo training in respect of the protection of vulnerable adults. EVIDENCE: The home was seen to have a complaints policy and procedure, though this needs to change to reflect the CSCI office contact address, which is now in, Harrow. Also, there was no complaints record format seen which needs to be available and used to record details and outcomes of any complaint. A requirement is made to ensure a suitable record is available. The manager advised there had been no complaints received in the last six months and people spoken with during the inspection did not raise any complaints or concerns. The manager said there were no current Protection of vulnerable adults investigations ongoing in connection with the home. The home had a policy and procedure in respect of protecting vulnerable adults from abuse, however, the policy and procedures utilised by the London Borough of Enfield could not be located at the time of inspection for reference if necessary by staff. Most staff had undergone training in 2006 from one of the registered providers who has a “train the trainer” certificate. Some staff had not done training in this St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 14 area and this needs to be rectified. A requirement is made in the report to cover this issue. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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. 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. Some improvements to the external and internal environment and facilities would enhance the quality of life for people living at the home. EVIDENCE: The home was found to be generally suitable and comfortable for the people living there. Bedrooms were seen to be personalised and people living there said they liked the environment. The home was clean and free from offensive odours during the visit and people living there said this was the usual experience they had. The inspector acknowledged there were plans in progress to improve the decoration of certain communal areas of the home such as hallways and the inspector recommends the office is included in these plans. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 16 Some enhancements to the premises and facilities were needed to improve the life of people further. The assisted bathroom on the first floor is disliked by some people, as the bath has to be filled with them already inside. Also, a hoist is stored in this bathroom, which is inappropriate given the small size of the room. Some armchairs in the lounge were seen to be in need of replacement. In the ground floor bathroom, some retiling is required. A couple of window frames at the rear of the building needed repainting or replacing. All these areas were pointed out and discussed with the manager at the time of inspection and a requirement for these issues to be addressed is given. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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 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 living at the home benefit from skilled staff in suitable numbers to meet their needs. Staff are recruited in a manner that safeguards people living at the home. EVIDENCE: The home has a manager and two care staff working throughout the day. At night there is one member of staff awake and one sleeping in. In addition there is a cook and a housekeeper. People felt that there were sufficient staff to meet their needs and during the inspection there was no sense that this was not the case from observation and discussion. However, the home is registered for sixteen people and on the day of inspection only fourteen were accommodated, so review of current staff levels if new people with high needs are admitted, would be a necessary management task. Fifty percent of the current care staff have achieved national vocational qualifications in care at level two or above. It was clear from records and discussion with staff that they had received a range of relevant training to assist them with their roles. This included: Dementia training, moving and handling, infection control, food hygiene and fire safety. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 18 Staff files were examined which showed that staff had filled out application forms, attended interviews and had references taken up before being offered employment. Criminal records bureau checks were seen to have been undertaken and photographic evidence of identity had been obtained. Staff spoken with confirmed they had undergone these recruitment procedures and that they were subject to a period of induction. They said supervision was an on-going part of their employment. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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 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 adequate. . This judgement has been made using available evidence including a visit to this service. The home needs to make application to register a manager. Some further work is needed to fully implement a quality assurance system within the home. Financial records for people living at the home need some improvement. Whilst health and safety of people is generally promoted and protected, an electrical safety certificate must be available. EVIDENCE: At the time of inspection, the home did not have a registered manager. A manager had been appointed to work at the home by the providers and had been doing so since October 2006. However, no application to register him with the CSCI has yet been made by the providers to the knowledge of the inspector. A requirement to make application to the CSCI is made in this St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 20 report. The manager is currently undertaking an National vocational qualification at level four in health and social care and hopes to study for the registered managers award after completing the nvq. The staff at the home spoke about the good support they receive from the manager and it was clear a good rapport existed between the manager and staff. AS mentioned earlier in the report, people living at the home have regular meetings where they can influence how the home can be run in their best interests. Satisfaction surveys had been carried out on people living at the home and results collated. However, there was no action plan seen based on these surveys and this needs to be part of a full quality assurance cycle of audit, review and action planning. A requirement is made in respect of this improvement. The home was holding monies on behalf of a number of people living at the home. These were randomly sampled and found to be correct in relation to the records held for each person. Although receipts were available for various items, some purchases on behalf of people did not have written receipts and this needs to be rectified for the future to ensure good accounting standards. A requirement is made regarding this issue. Certificates of safety and soundness were seen for fire equipment, water, gas and lift. A certificate proving the up to date soundness of the electrical installations at the home was not available and a requirement is made to this effect. No obvious safety hazards were seen during the inspection and staff have received training in health and safety issues. St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 2 St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 22 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 OP16 Regulation 22(8) and schedule 4 13 (6) Requirement The registered person must keep a record of complaints and have a recording format for that purpose available for inspection The registered person must ensure that all staff receive training in the protection of vulnerable adults from abuse and that this is appropriately documented. A copy of the local borough’s policy and procedure should also be available. The registered person must ensure that the premises and facilities therein meet the needs of the people living there and remain comfortable and well maintained. (See standard nineteen for detail) The registered person must make application to the CSCI for the registration of a manager to manage the care home The registered person must ensure that a system of quality assurance is fully developed within the home which involves auditing of satisfaction surveys and creating action plans to DS0000059522.V336690.R01.S.doc Timescale for action 31/07/07 2. OP18 31/08/07 3. OP19 OP21 16 and 23 30/09/07 4. OP31 8 31/07/07 5. OP33 24 31/08/07 St Catherine`s Home Version 5.2 Page 23 6, OP35 Schedule (9) 7. OP38 23 meet any identified shortfalls in the service provision The registered person must 31/07/07 ensure that receipts for items purchased on behalf of people living at the home are obtained and available for inspection. The registered person must 31/07/07 provide an up to date certificate of safety in respect of the electrical installation 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. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that where appropriate a “Goal achievement” approach is adopted in peoples care plans St Catherine`s Home DS0000059522.V336690.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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