CARE HOMES FOR OLDER PEOPLE
St Catherine`s Home 35 Derby Road Enfield Middlesex EN3 4AJ Lead Inspector
Anthony Lewis Unannounced Inspection 3rd October 2005 09:00 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.V251048.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 Home DS0000059522.V251048.R01.S.doc Version 5.0 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) 01920 486 137 020 8804 1136 ADR Care Homes Ltd Bridget Teresa Hills Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Older people with a diagnoses of severe dementia must not be admitted. 30th June 2005 Date of last inspection Brief Description of the Service: St Catherine’s 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 a residential part of Enfield, which was extended and opened in 1986. There are shops and bus and rail routes a short distance from the home. The home has twelve single bedrooms and two double bedrooms. In addition, there is, to the ground floor, a large kitchen, and a large through lounge and a dining room. There is also a lift to the first floor. To the front of the home, there is off street parking for several vehicles and to the rear, there is a large well kept garden. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 3rd October 2005 at 09:00 and was completed at 15.05pm. The registered manager and registered providers were available throughout the inspection process and were all very helpful and accommodating. To gather evidence for this inspection, five residents were spoken to informally. The registered manager’s National Vocational Qualification assessor was spoken to formally. Two members of staff were also spoken to informally. An extensive tour of the home was conducted with a care worker. Evidence was also gathered by viewing five resident and six staff files along with safety certificates and various records and other files. What the service does well: What has improved since the last inspection? What they could do better: St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 6 There are eighteen requirements from this inspection, thirteen of them are new and five are restated. There are also two recommendations made. The staff team must ensure that all medication administered is signed for and that any gaps are investigated and a record kept. Resident’s wishes in the event of them becoming terminally ill and dying must be sought. To ensure that residents are protected at all times, all complaints must be reported, investigated and the outcome recorded. Staff must ensure that wedges are not put underneath doors to keep them open and instead a self closing device must be fitted. To ensure that the senior care staff understand their roles and responsibilities, they must be supplied with a job description. All staff must have a recent photograph in their file. No staff should be allowed to start work in the home without first ensuring that their two references, Criminal Records Bureau (CRB) check are obtained and their application form is filled in correctly to ensure that residents, other staff and visitors are protected. Where possible, resident’s money should be locked in the home’s safe or locked in the resident’s bedroom cupboard. Residents must be informed of the risks of leaving their money unsecured in their bedroom and a review of the resident’s money and the homes safe keeping of petty cash is undertaken. Staff must receive regular supervision to ensure that their personal development is being monitored and that they are being supported. A review must be undertaken of the home’s fire procedures to ensure the safety of residents, staff and visitors to the home. In order to ensure that the home is safe and contraventions have been complied with, the LFEPA must be contacted to carry out an inspection of the home. It is recommended that two members of the staff team carry out interviews in the future. It is also recommended that an interview policy and procedure is in place to ensure recruitment procedures are followed. 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 Home DS0000059522.V251048.R01.S.doc Version 5.0 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.V251048.R01.S.doc Version 5.0 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 the following standard(s): 1 and 6. Prospective residents to the home for permanent or temporary admission and interested parties have the information they need to make an informed choice as to whether the home is suitable to move into and can meet their individual needs. EVIDENCE: The home’s statement of purpose and service users guide were viewed and found to be comprehensive with information regarding the home and the service that residents can expect to receive from the staff team. The registered provider stated that the home does take residents on intermediate care. He went on to explain the provisions for residents to improve their independence and eventually return to their own home. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 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 the following standard(s): 9, 10 and 11. Residents are potentially being put at risk due to staff not ensuring that they follow the correct recording procedures when administering medication to residents. The staff are also not ensuring that resident’s wishes, in the event of their death, is recorded to ensure that funeral arrangements are dealt with sensitively and professionally. EVIDENCE: All of the resident’s Medication Administration Record (MAR) charts were viewed. There were a number of gaps in the administration charts where the medication has been administered but has not been signed for or nonadministration coded as to the reason for the non-administration. The gaps were found in regards to administration at all times of the day. A requirement is made that the registered persons must ensure that all medication administration is signed for and any gaps found are investigated and recorded. Staff were indirectly observed knocking on resident’s bedroom door prior to entering. Staff were also indirectly observed interacting with residents in a respectful and sensitive manner. Two residents, who share a room, have a screen to ensure their privacy, especially with regards to personal care. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 10 Although there has been some progress with obtaining resident’s wishes in the event of them becoming terminally ill and dying, some resident’s wishes have still not been recorded, as was a requirement at the previous inspection. This requirement is restated. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15. Residents are confident that the home will support them to exercise choice with regards to controlling their own finances and that the home will ensure that their dietary needs are met. EVIDENCE: The registered person stated that residents or their relatives handle their finances. The home has a safe, which the registered provider stated, was available for residents who wish to store any personal items or money. The home’s cook was spoken to at length regarding the menu and dietary needs of some residents. The cook has a good understanding of the dietary needs of residents who are diabetic. The menu contained wholesome varied meals. Residents spoken to stated that they enjoy the meals that the home provides. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 12 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): 16 and 17. Although the home has a comprehensive complaints procedure and a complaints book in place, staff are not ensuring that the home’s complaints procedures are followed fully. EVIDENCE: The home’s complaints file was viewed and the last complaint was recorded on 26th November 2004. The reasons why there has been no complaints recorded for nearly a year was discussed with the registered providers and the registered manager. A requirement is made that the registered persons must ensure that all complaints are reported, investigated and the outcome recorded. There have been two thefts of money in the home recently. A resident reported that money was stolen on 25th September 2005 and money has recently been stolen from the office. The registered providers and the registered manager have reported the incidents to the correct authorities and an investigation is underway. The registered persons are looking into improving security in the home. The home has separate incident and accident books and staff are recording all incidents and accidents appropriately. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 13 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, 20 and 22. Although all areas of the home are bright and comfortable and specialist equipment are available to aid residents within the home, staff’s practice of wedging doors open, is potentially putting residents, visitors to the home and themselves at risk in the event of a fire occurring. EVIDENCE: A tour of the home was conducted and found to be generally in good order internally and externally. Although most areas of the home are generally safe, the staff are putting residents, visitors and themselves at risk in the event of a fire occurring by placing wooden wedges underneath doors to keep them open. Wedges were found under some bedroom doors and other doors throughout the home. A requirement is made that the registered persons ensure that all doors throughout the home are fitted with a device that can self close in the event of the fire alarm sounding and all wedges are removed. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 14 All communal areas of the home were seen to be safe. The home has a large through lounge, which is well lit and offers comfortable seating for residents. Residents spoken to all said that the accommodations are comfortable. The home has specialist equipment for residents to aid their mobility. Equipment such as grab rails, commodes, wheelchairs and walking frames are provided to residents. There is also assisted baths for resident’s use. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 15 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, 29 and 30. The registered manager is endangering the residents, staff and visitors and leaving them open to abuse by not ensuring that the correct recruitment procedures are followed and by not ensuring that sufficient information is received prior to staff commencing working in the home. EVIDENCE: The home’s rota was viewed and indicated that there are usually two to three staff on duty on the early shift and two staff on the late shift. Residents spoken to said that their personal care needs are being met by the staff. One said that staff are very flexible with personal care in that she is able to sleep in if she chooses. A recommendation was made at the previous inspection that the registered providers review the staffing in the home and consider appointing a deputy manager or two senior care workers to ensure that there is always a senior person on duty at all times. Although the registered providers have now appointed two senior support workers, on looking through their file, it was found that they do not have a job description. A requirement is made that the two senior care staff are supplied with a job description. Six staff files were viewed and although most now contain a photograph of the staff, which was a requirement at the previous inspection, some staff did not have a photograph of themselves in their file. This requirement is restated. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 16 An immediate requirement was issued because two of the staff working in the home did not have the required documentation. Neither had a current Criminal Records Bureau (CRB) check or a Protection of Vulnerable Adults (POVA) first check prior to starting working in the home, although both staff had a (CRB) from their previous employment. Another immediate requirement was issues because the same two staff in question did not have any references in their file. The application form for one of the staff in question was not filled in correctly. Both staff have been working in the home since July/August 2005. The registered manager stated that she interviewed both staff on her own. A requirement is made that the registered persons must ensure that prospective staff application forms are correctly filled in and the information contained is authentic. The home has produced a reasonable training programme and the registered providers are ensuring that all staff receives the statutory training, refresher training and ongoing training. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 17 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, 35, 36 and 38. The health and safety of residents, staff and visitors to the home are being put at risk due to the registered providers not ensuring that all possible fire safety procedures are followed and that information is recorded correctly and stored safely. EVIDENCE: The registered manager has been working at the home for the past fifteen years and has a good relationship with the residents and the staff team. She is at present undertaking her National Vocational Qualification (NVQ4). Her NVQ assessor was available to speak to. She said that the registered manager is progressing well and should complete her NVQ4 by the spring of 2006. A resident has recently informed the registered providers that money was stolen from her bag, which she keeps with her most of the time. The registered manager also stated that money was stolen from an office drawer recently. The registered providers have informed the correct authorities and an
St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 18 investigation is underway. The registered provider stated that residents do not want their money deposited in the home’s safe and would rather keep their money in their bedroom. A requirement is made that a review of the safe keeping of the homes petty cash and resident’s money is undertaken and residents who wish to keep their money in their bedroom sign to state this. Although staff are now receiving supervision as was a requirement at the previous inspection, on looking through six staff files, supervision is sporadic in that some staff are going more than two months without receiving any supervision. The content of the supervision is limited with no structure. This requirement is revised and restated. Although the home now has a comprehensive fire risk assessment in place. The last recorded fire drill took place on 29th April 2005 and although fire tests are carried out weekly, they are not being recorded correctly in that staff are not recording the information in the correct places and the information that is recorded does not state clearly what has been tested. A requirement is made that the registered persons ensure that a review of the fire procedures is carried out and that all staff are aware of the correct procedures when carrying out and recording tests and that a fire drill is carried out at least quarterly and recorded correctly. The registered manager could not find the last London Fire and Emergency Planning Authority (LFEPA) certificate to check and see if the three contraventions have been complied with, as was a requirement from the previous inspection. A requirement is made that the registered persons ensure that the (LFEPA) are contacted regarding an inspection of the home and that any contraventions identified are complied with. Once received, a copy of the LFEPA certificate must be forwarded to the Commission. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X x 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 x 9 1 10 3 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 2 2 3 X 3 X X X X STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 1 1 X 1 St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13 2 Requirement The registered persons must ensure that the administration of all medication is signed for on the (MAR) chart and any nonadministration coded as to the reason why the medication was not administered. The registered persons must monitor the administration charts daily and bring any omissions in the completion of the administration charts to the relevant member of staff’s attention immediately and record the outcome. (Timescale of 29/04/05 not met). This requirement is revised and restated. The registered persons must ensure that in the event of a resident becoming terminally ill and dying, that their wishes regarding their funeral arrangements are recorded in their file. (Timescale of 22/07/05 not met). This requirement is restated. The registered persons must ensure that all complaints are reported, investigated and the outcome recorded.
DS0000059522.V251048.R01.S.doc Timescale for action 28/10/05 2 OP11 12(3) 23/12/05 3 OP18 22(1) (3)(4) 28/10/05 St Catherine`s Home Version 5.0 Page 21 4 OP19 23 (4)(a)(c) (i)(v) 5 OP27 Sch 6(e) 6 OP29 Sch 2(1) 7 OP29 19 Sch 2 8 OP29 19 Sch 2 Sch 4 9 OP29 19 Sch 4 6(f) 10 OP 35 16(2)(l) 11 OP36 18(2) The registered persons must ensure that wedges are not used to keep doors open and instead an approved device that automatically closes in the event of the fire alarm sounding is fitted. (Timescale of 01/02/05 not met). This requirement is revised and restated. The registered persons must ensure that the two senior care staff employed in the home are supplied with a job description. The registered persons must ensure that all staff files contain a recent photograph of them. (Timescale of 29/04/05 not met). This requirement is restated. The registered persons must ensure that no staff are allowed to start working in the home without first obtaining a CRB check or POVA first check. The registered persons must ensure that two satisfactory references are obtained prior to staff starting working in the home. The registered persons must ensure that prospective staff’s application form is correctly filled in and the information contained is authentic. The registered persons must ensure that a review of the safe keeping of the home’s petty cash and resident’s money is undertaken and residents who wish to keep their money unsecured on their person or in their bedroom sign to state this. The registered persons must ensure that all staff, including the registered manager, receive formal supervision at least six times a year and that a record is kept in their file. (Timescale of
DS0000059522.V251048.R01.S.doc 28/10/05 28/10/05 28/10/05 06/10/05 05/10/05 28/10/05 28/10/05 23/12/05 St Catherine`s Home Version 5.0 Page 22 12 OP38 23(4)(a) (c)(v)(e) 23(4) (a)(c) (v)(e) 13 OP38 22/07/05 not met). This requirement is revised and restated. The registered persons must ensure that a review of the home’s fire procedures is carried out. The registered persons must ensure that the LFEPA is contacted to carry out an inspection of the home and that any contraventions identified are complied with. 28/10/05 28/10/05 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 OP29 OP29 Good Practice Recommendations It is recommended that all interviews for potential employees are carried out by at least two members of staff under appropriate interviewing procedures. It is recommended that an interview policy and procedure is in place to ensure that the home is operating a thorough recruitment procedure based on equal opportunities and ensuring that residents, staff and visitors are protected and that the procedures are followed correctly. St Catherine`s Home DS0000059522.V251048.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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