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Inspection on 04/04/05 for St Catherine`s Home

Also see our care home review for St Catherine`s Home for more information

This inspection was carried out on 4th April 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector was able to speak to four residents throughout the inspection. All had very positive things to say about the care staff and the way in which the home is managed. Two residents said that they were able to talk to the manager about any concerns that they may have. All said that the staff team are very caring and helpful and kind. Comments made regarding the food were positive. All of the residents said that they enjoyed all of the meals and that the portions were adequate. The inspector was able to informally observe the staff team at work and felt that the staff team had a good rapport with the residents and with each other. The care staff`s approach was caring, helpful, and considerate at all times. Care workers and residents were all on first names and all seemed relaxed. The atmosphere of the home was warm, friendly and homely. The staff team have ensured that the cleanliness of the home is well maintained.

What has improved since the last inspection?

At the time of the inspection, the home was having minor painting and decorating work to the hallway and one of the vacant bedrooms. The manager stated that various parts of the home had been redecorated recently and that decorating is ongoing.

What the care home could do better:

The majority of the requirements in this report refer to the administration of the home by the registered manager and the registered provider. The inspector was very concerned that the majority of the requirements from the previous inspection had not been met. Others had been attempted but not fully completed. There were concerns that the registered manager does not have a deputy or any senior care staff to assist in the running of the home and to delegate certain tasks to. The registered provider is not paying enough attention to a number of regulations and requirements. Out of the twenty-eight requirements identified at this inspection, seven requirements were relating to resident`s and staff`s files and information required, six were relating to staff training, three were relating to risk assessments, five were relating to resident`s health and safety, three were relating to resident`s choices in the home, two were relating to the registered provider producing certain information, one was relating to staff supervision and one was relating to the recruitment of staff. One recommendation was made regarding staffing.

CARE HOMES FOR OLDER PEOPLE St CATHERINES HOME 35 Derby Road Enfield Middlesex EN3 4AJ Lead Inspector Anthony Lewis Unannounced 4 April 2005 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 HOME Version 1.00 Page 3 SERVICE INFORMATION Name of service St Catherines Home Address 35 Derby Road, Enfield, Middlesex EN3 4AJ 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) 020 8884 1136 Mr Anthony Rudd of ADR Care Homes Ltd Bridget Teresa Hills PC Care Home only 16 Category(ies) of Old Age, not falling into any other category (16) registration, with number of places Conditions of registration Date of last inspection 1 Older people with a diagnoses of severe dementia must not be admitted. 8 October 2004 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 which was extended and opend in 1986. There are shops and bus and rail routes a short diastance from the home. The home has twelve single bedrooms and two double bedrooms. In addition, there is, to the ground floor a large kitchen, a large through lounge and a dining room. There is also a lift to the first floor. To the front of the building, there is off street parking for several vehicles and to the rear, there is a large well kept garden. St CATHERINES HOME Version 1.00 Page 4 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on Monday 4th April 2005 at 9.40am and was completed at 6.35pm. The registered manager was available throughout the inspection and the registered provider for most of the inspection. Both were very helpful and accommodating along with the rest of the staff team. The inspector was able to speak to two care staff together and four residents in private. At the previous inspection, there were thirty-five requirements, at this inspection there are twenty-eight requirements, twenty have been restated. There is also one recommendation. What the service does well: What has improved since the last inspection? At the time of the inspection, the home was having minor painting and decorating work to the hallway and one of the vacant bedrooms. The manager stated that various parts of the home had been redecorated recently and that decorating is ongoing. St CATHERINES HOME Version 1.00 Page 5 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St CATHERINES HOME Version 1.00 Page 6 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 HOME Version 1.00 Page 7 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) 1,2,3,4 and 5 The registered providers have compiled a comprehensive statement of purpose and service users guide for the home and potential new residents to the home. Both contain comprehensive information for potential residents to the home to make an informed decision regarding whether to move into the home or not. The admissions process for potential residents to the home is comprehensive and user friendly. The home is able to meet the needs of existing residents, providing a good standard of care. EVIDENCE: The statement of purpose and the service user guide, both were seen to be satisfactory, setting out all of the information required in NMS1. At the previous inspection, a requirement was made that service users views are included in the service users guide. This has been complied with. At the previous inspection, a requirement was made that resident’s files contain a copy of the terms and conditions of the home and the fees paid. This requirement is restated. St CATHERINES HOME Version 1.00 Page 8 The registered providers were able to described in detail of the admissions procedure prior to a news resident moving into the home. At the previous inspection, a requirement was made that resident’s files, especially for new admissions, contain initial assessments and care plans. Four residents files were seen, including the file of the most recent resident to the home, all contained a copy of their assessment and care plan. A requirement was made at the previous inspection that for some of the residents who had dementia care that the registered person would need to apply to the CSCI for a variation. At this inspection, the registered providers stated that previously there were three residents with dementia and that two of these residents have now died. The registered provider went on to tell the inspector that the conditions of registration allow for one resident with dementia to live in the home without applying for a variation. The registered manager informed the inspector that she had contacted Barnet College with regards to dementia training for staff and are awaiting a reply. Dementia training for all staff was a requirement at the previous inspection. This requirement is restated. The statement of purpose has clear information on the admissions procedure and also information for emergency admissions to the home, which includes an initial informal assessment and a full assessment within five days. St CATHERINES HOME Version 1.00 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 and 11. From indirect observations of residents and staff and informal chats with residents, care staff the manager and the registered provider, it is clear that the residents are happy living in the home and are well cared for and that they are treated with respect and dignity at all times and there emotional needs are being met. Record keeping is limited in that the registered providers have not developed a strategy for documenting important information, which is vital in assuring that resident’s health and personal care needs are met. EVIDENCE: Little progress has been made with regards to documenting information pertaining to health care needs such as health care appointments. There is some evidence to indicated that residents are being seen by health care professionals but little recording is maintained to show what the outcomes were and what action the staff team will take as to health issues such as incontinence control and in the event of a resident having pressure sores. St CATHERINES HOME Version 1.00 Page 10 There are insufficient risk assessments in place in resident’s files. The accident book clearly shows that falls within the home are a common occurrence, yet there are no risk assessments to minimise or eliminate the risk. If the registered providers do not address these issues, it could have health and safety consequences to a resident and ramifications to the integrity of the home. Previous restated requirements made for resident’s plans to be reviewed monthly and for the residents and/or their representative to be involved in the consultation concerning the content of the resident’s plans have not been met. The registered providers informed the inspector that they have tried to involves resident’s representatives but have been unsuccessful with some. This is a restated requirement. The accident file was viewed and many of the accidents to residents were to do with falling over. On examining four resident’s care plans, the inspector could not find any risk assessments regarding falling or other risks to residents, which was a requirement at the previous inspection. This is a restated requirement. Another requirement made was that resident’s care plans be updated monthly. There was some evidence that residents care plans were being updated monthly but this was inconsistent. This is a restated requirement. At lunch, the care staff were indirectly observed to be caring, supportive and patient with residents. The manager informed the inspector that none of the residents have pressure sores and that a district nurse visits the home twice a day and is kept informed of any new health issues to residents. On touring the home, there was a smell of urine in two residents bedrooms. The registered manager informed the inspector that the two residents in question are incontinent at times. A requirement is made that an assessment of resident’s continence promotion is undertaken and where residents are assessed as incontinent, staff receive the necessary training in order to fully support the resident/s. No resident’s file had a photograph of them inside. The registered provider has taken some pictures, which were on the office desk, and envisages that the others will be completed in the near future. A requirement is made that the registered providers ensure that all resident’s files contain an up to date photograph of them. Several resident’s files did not have clear information on resident’s health appointments with outcomes and actions. This is a restated requirement. There was no evidence that residents had received nutritional assessments by a dietician and or a district nurse, which was a requirement at the previous inspection. This is a restated requirement. St CATHERINES HOME Version 1.00 Page 11 Residents were seen to be moving about the home independently using walking frames. Bathrooms and toilets had aids and equipment provided. A requirement was made at the previous inspector that controlled drugs be stored in a metal drugs cabinet, this requirement has been met. At the previous inspection, a requirement was made that a list of all staff that have received medication training should be held on file in the medication cupboard with sample as per staff signatures used on the MAR sheets has not been complied with. This is a restated requirement. On viewing the MAR sheets for several residents, the inspector noticed a number of errors. Some staff had been either giving medication and not signing or not giving medication and not signing. Medication that clearly states to be given nightly was being given sporadically and one member of staff signature was not legible. A requirement is made that the registered providers have a thorough review with all care staff of the policies and procedures regarding medication administration and that where identified staff receive retaining. One service user informed the inspector that she enjoyed spending time alone in her bedroom. The inspector noticed that in the bedroom that two residents share, there was a retractable screen for privacy when necessary. The inspector observed care staff knocking on bedroom doors prior to entering. Care staff were overheard talking and bantering in a respectful and courteous manner with residents. The registered manager informed the inspector that one resident had a telephone in her bedroom for her own personal use and that there was a pay phone in the hall for residents to use or if they wished to speak in private, they could use the office cordless phone. The inspector viewed a number of resident’s files and found that some did not contain information on resident’s wishes in the event of them becoming terminally ill or with regards to their funeral arrangements. This was a requirement at the previous inspection. This is a restated requirement. St CATHERINES HOME Version 1.00 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) 14. There needs to be a more robust accounting and recording of resident’s monies to prevent the abuse resident’s finances. Inventories are not comprehensive and do not reflect all personal belongings owned by residents. EVIDENCE: The registered providers informed the inspector that residents bring their personal belongings and furniture when admitted into the home. The registered providers informed the inspector that resident’s family handle all but two of the resident’s financial affairs. The other two residents handle their own finances, although there is no information as to what support the staff team give with respect of the two residents who have control of their own finances. A requirement is made that the registered providers ensure that any support that care staff give with respect to resident’s finances is recorded in their care plan. The registered manager has begun inventories for some residents, however, they are not comprehensive and many residents have no inventories. A requirement is made that registered providers ensure that all residents supported with compiling inventories for all possessions and that a copy is retained in their file. The inspector was able to sit and have lunch with the residents. The meal was appealing and tasty. Residents spoken to said that they enjoyed the meals. St CATHERINES HOME Version 1.00 Page 13 Some residents were observed eating in the lounge and others in the dining room as a matter of choice. St CATHERINES HOME Version 1.00 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 and 18. Residents are confident that any complaint that they make will be dealt with appropriately by the registered providers. Evidence from the last two complaints, show that the registered providers take all complaints seriously and act on them promptly and to the satisfaction of the resident/s. The registered providers have not ensured that all staff receive training in protection of vulnerable adults. This must be addressed as a matter of urgency. EVIDENCE: The home has a complaints procedure for resident’s, which states clearly how, and who to complain to and the timescale for dealing with the complaint. The complaints procedure also gives information on referring complaints to the Commission if the resident is not satisfied with the outcome of their initial complaint. Residents spoken to said that they would direct any complaint to the manager or registered provider. They also said that they felt that if they had a complaint, the staff team would take it seriously and that the staff always listened to them. On viewing the complaints file there had been only two complaints in the past twelve months and the registered providers dealt with them promptly. St CATHERINES HOME Version 1.00 Page 15 Although the registered providers have contacted the local authority for staff training in adult protection and are awaiting a response, they must be more proactive in obtaining dates for the training to ensure that the potential risks of abuse to residents, either directly or indirectly is eliminated. At the previous inspection, a requirement was made that all staff receive training in adult protection. On speaking to the registered providers, this requirement had not been met, although they had been in touch with the local authority and are waiting a training date. This is a restated requirement. St CATHERINES HOME Version 1.00 Page 16 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, 21, 23, 24, 25 and 26. Generally, the décor of all areas in the home is bright and tasteful. Bedrooms are individualised with a comfy feeling. A testament to the registered providers desires to ensure that all residents are comfortable living in the home. Limited progress has been made regarding risk assessments for residents who choose to have their doors left open, especially at night. EVIDENCE: On touring the building, all areas were found to be generally clean and tidy. A builder was at the home doing general painting and decorating to two vacant bedrooms and the hallway. The work did not seem to infringe on resident’s freedom of movement or their safety. The home has sufficient bathrooms and toilets, which have been adapted for residents with physical disabilities all, were clean and tidy. St CATHERINES HOME Version 1.00 Page 17 All resident’s bedrooms seemed roomy comfortable and decorated and furnished to their own personal style meet their individual needs. All bedroom radiators were fitted with guards and temperature control valves. Most bedrooms had pictures of family and loved ones and other personal items. The lounge and dining room were clean, tidy and had a pleasant ambiance to them. Residents spoken to said that they felt very comfortable living in the home. A requirement was made at the previous inspection that residents have lockable storage space in their bedroom. This requirement has not been met. The registered manager informed the inspector that some residents did not want lockable cupboards in their bedroom. This was not reflected in their care plans. This is a restated requirement. The inspector noticed that a number of doors were left open. The registered manager said that one service user likes his bedroom door to be left open at night. The lounge door was propped open by a chair. A requirement was made at the previous inspection that an assessment should be carried out for service users who wish to keep their bedroom doors open at night and that a door guard is fitted to the smoking room fire door and that the Commission is notified when it is fitted, this has not been done. This is a restated requirement. St CATHERINES HOME Version 1.00 Page 18 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 and 30. The registered providers do not see the necessity for a senior staff. The home has fourteen care workers and the registered manager, there is no senior staff in place, such as a deputy manager or senior care workers to oversee the smooth running of each shift and to deal with administrative issues and tasks. It is unacceptable that the registered manager is on-call twenty-four hours a day seven days a week. EVIDENCE: On examining the staff rota, there was no evidence of who is in charge or the responsible person when the registered providers are not available or on duty. A recommendation is made in this report that the registered provider consider appointing a deputy manager or two senior care workers. The rota for the past few weeks was written in pencil and parts rubbed out. There was also pages a the front of the rota that have been ripped out. When the inspector arrived at the home, the registered providers were not available. When asked who was in charge, the care worker who answered the door stated that there was no person in charge. A requirement was made at the previous inspection that the registered manager is not on call twenty-four hours a day seven days a week, that the rota clearly states the responsible person on duty on each shift, days off and annual leave. This standard is not met. On viewing the rota and speaking with the registered manager, it became clear that she is still permanently on-call. This is a restated requirement. St CATHERINES HOME Version 1.00 Page 19 Staff numbers are sufficient to meet the needs of the residents. Residents spoken to said that they were happy with the level of care provided. A number of issues came to light when viewing some staff files. No staff file contained a recent photograph and some staff did not have two references. A requirement is made that the registered providers ensure that all staff have a recent photograph on their file and that all staff have two references as set out in Schedule 2 of the Care Homes regulations. One member of staff was working under supervision until her CRB had been received. A requirement is made that the registered providers do not employ staff without a satisfactory CRB. This is a restated requirement. The home does not have a training programme to highlight staff who need to undertake certain training courses and staff who may need refresher training. Staff files examined did not all have a copy of their training certificates for inspection and not all staff has received the statutory training required. A requirement was made at the previous inspection that the registered providers ensure that all staff have the statutory training such as; health and safety, fire awareness and that a training programme is put in place. This requirement is restated and amended. St CATHERINES HOME Version 1.00 Page 20 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, 33, 34, 36, 37 and 38. There is no noticeable time management with regards to administration tasks within the home. There is no consistency and robust administration practices. The registered provider has not been proactive in quality assurance monitoring. There is no quality assurance system in place to monitor the quality and consistence of care within the home. There is limited consultation with residents as to their views. Resident’s health and safety is clearly being put at risk due to lack of robust monitoring and recording procedures, especially with regards to fire safety procedures. EVIDENCE: Through indirect and direct observation of the registered manager, it was clear that her style of managing the home was open and inclusive. Care staff and residents seemed at ease in her company and banter that was witnessed was St CATHERINES HOME Version 1.00 Page 21 respectful and dignified. Staff and residents spoken to were all complimentary towards the manager. One resident said that she felt comfortable talking to the manager about any issues. At the previous inspection, a requirement was made for an unannounced Regulation 26 visit to take place once a month and a written report to be held in the home and a copy be sent to the Commission. This has not been met. This is a restated requirement. The home has three vacancies. The registered provider stated that this is impacting on the financial viability of the home. At the previous inspection a requirement was made that the home has in place an annual development and business plan, this requirement was not met. This is a restated requirement. Staff files viewed indicated that many of the staff were not receiving formal supervision at least six times a year, this was a requirement at the previous inspection. This requirement is restated and amended. Resident’s files are securely kept in a cabinet in the office, with access limited. Copies of residents care plans were seen in their bedrooms. There were concerns that staff files were left on the office desk and not kept securely in the home. A recommendation is made that the registered provider ensure that staff files are kept securely and access limited to relevant individuals. Two requirements made at the previous inspection had not been met. Firstly, that the registered person ensures that staff receive fire safety and infection control training. The registered manager stated that she was waiting a date from Barnet College for staff training. This is a restated requirement. Secondly, that the home reviews and updates its fire risk assessments. This is a restated requirement. Fire tests were seen to be carried out weekly by the registered manager. The LFEPA carried out an inspection of the home on 24/03/05 and the following contraventions were identified: * * * * * * Written fire assessments to be provided. Written emergency fire plans to be provided. Employees to be trained on how to use fire extinguishers. Fire alarm tests using different call points in chronological order. Emergency lighting to be tested monthly and record kept in a log book. All fire doors to close fully and unless help open by approved devices should be closed at all times. A requirement is made that the registered providers ensure that the above contraventions identified by the LFEPA are complied with. St CATHERINES HOME Version 1.00 Page 22 The last recorded fire drill took place on 11.01.04. A requirement was made at the previous inspection that a fire drill takes place by the 15/11/04, and thereafter every three months. This requirement has not been met. This is a restated requirement. A requirement is made The inspector was concerned that care staff are recording incidents in the accident book and that the home did not have a book/file for incidents in the home. A requirement is made that the registered providers ensure that the home has an incident book/file. St CATHERINES HOME Version 1.00 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 x COMPLAINTS AND PROTECTION 2 x 3 x 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 x 3 1 2 x 2 3 1 St CATHERINES HOME Version 1.00 Page 24 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 OP2 Regulation 5 (1) (b) Requirement The registered persons must ensure that all residents have a written statement of terms and conditions, which meet the requirements of NMS2. This must be held on files and available for insoection. (Previous timescale of 01/02/05 not met). The registered persons must ensure that staff receive dementia training to ensure that residents with dementia care needs are supported appropriately. (Previous timescale of 31/03/05 not met). The registered person must ensure that residents or their representatives sign the care plans. This was an immidiate requiremnt from the previous inspection. (Previous timescale of 08/12/04 not met). The registered persons must ensure that the home reviews and updates its workplace risk assessments. Mesures identified to minimise risks must be clearly identified. (Previous timescale of 01/01/05 not met). The registered persons must Version 1.00 Timescale for action 06/05/05 2. OP4 18 (1) (c) (I) 27/05/05 3. OP7 15 (1) (2) 01/05/05 4. OP38 13 (4) 29/05/05 5. OP7 15 (1) (2) 29/05/05 Page 25 St CATHERINES HOME 6. 8 13(1) (b) 7. OP37 17 (1) (a) and Schedule 3 (2) 17 (1) (a) and Schedule 3 (a) 17 (1) (a) and Schedule 3 (a) 8. OP8 9. OP8 10. OP9 13 (2) ensure that care plans are reviwed monthly and that this is recorded. This was an immidiate requirement from the previous inspection. (Previous timescale of 08/12/04 not met). The regisreted providers must ensure that a full assessment and professional advice is sort for residents who may be incontinent and that staff the necessary training to enable them to fully supporft the residents. The registered providers must ensure that all residents files contain an up to date photograph of them in it. (Previous timescale of 01/01/05 not met). The registered providers must ensure that staff record clear information on resident’s health appointments with outcomes and actions. (Previous timescale of 31/12/04 not met). The registered persons must ensure that all residents receive a nutritional assessment by a dietician and or a ditrict nurse, with specific attention being paid to those residents at risk of developing pressure sores and those residents who are diabetic. (Previous timescale of 01/02/05 not met). The registered providers must ensure that a list of all staff who have received medication administration training is held on file in the medication cupboard with sample signatures used on the MAR sheets. The registered persons must ensure that all medication errors are investigated and a record kept of the outcome. The registered persons must also Version 1.00 27/05/05 29/04/05 13/04/05 29/04/05 29/04/05 St CATHERINES HOME Page 26 11. OP11 12 (3) 12. OP14 17 (1) (a) 13. OP14 17 (3) (a) and Schedule 4 (10) 13 (6) 14. OP18 15. OP24 23 (2) (m) 16. OP19 23 (4) (a) (c) (v) 17. OP27 18 (1) (a) ensure that all staff receive medication administration training or retraining where necessary. (Previous timescale of 01/12/04 not met). The registered persons must ensure that all residents files contain their wishes in the event of them becominfg terminally ill and dying. The registered providers must ensure that the financial arangements and support needs for residents to access their money is documented in their care plans. (Previous timescale of 01/02/05 not met). The registered providers must ensure that residents are supported in compiling an inventory of all residents personal belongs and a record kept in their file. The registered providers must ensure that staff receive adult protection training. (Previous timescale of 01/03/05 not met). The registered providers must ensure that each resident is offered a lockable storage space in their bedroom and that this consultation and assessment is documented. The registered providers must ensure that an assessment is carried out for residents who wish to keep their bedroom doors open an night. Automatic closing devices must be fitted to bedroom doors, the smoking room door and any all other fire doors that are kept open. (Previous timescale of 01/02/05 not met). The registered persons must ensure that a review of the emergency on-call arrangements in the home to enable the Version 1.00 27/04/05 29/04/05 27/05/05 29/04/05 29/04/05 27/05/05 29/04/05 St CATHERINES HOME Page 27 18. 19. OP29 OP30 Shedule 2 (1) 18 (1) (c) (i) 23 (4) (d) 13 (4) (c) 26 20. OP33 21. OP34 25 22. OP36 18 (2) 23. OP30 18 (1) (c) (i) 23 (4) (d) 13 (4) (c) 24. OP38 23 (4) (c) registered manager to have identified free time where she is not on-call seven a week, twenty four hours a day. (Previous timescale of 01/02/05 not met). The registered providers must enure that all staff files contain a recent photograph of them. The registered persons must ensure that all staff receive the staturory training and that a training programme is in place. (Previous timescale of 01/04/05 not met). The registered person must ensure that he visits the home unannounced on a monthly basis and prepare a written report, a copy of which must be sent to the Commission every month. (Previous timescale of 01/12/04 not met). The registered persons must ensure that the home has in place an annual development and business plans and that a copy be available for inspection. The registered persons must ensure that all staff, including the manager, receive formal supervision at least six times a year and that a record kept on their file. (Previous timescale of 01/03/05 not met). The registered providers must ensure that all staff receive fire safety and infection control training and that a copy of their certificates are kept in their file. (Previous timescale of 01/04/05 not met). The registered providers must ensure that a fire risk assessment is in place in the home and is available for inspection. (Previous timescale of 15/11/04 not met). Version 1.00 29/04/05 27/05/05 29/04/05 27/05/05 27/05/05 27/05/05 29/04/05 St CATHERINES HOME Page 28 25. OP38 17 (2) Schedule 4 (14) 26. 38 27. 29 37 (1) (e), Schedule 4 (12) (b) 19 (1) (b) (i). The registered persom must ensure that a fire drill takes place and recorded. In future a fire drill should takde place at least every three months. (Previous timescale of 15/11/04 not met). The registered providers must ensure that all incidents are recorded in a incident book. The registered persons must ensure that staff are not employed to work in the home without first obtaining a satisfactory CRB. (Previous timescale of 08/12/04 not met). The registered persons must ensure that all contraventions identified by the LFEPA are complied with. 29/04/05 29/04/05 13/04/05 28. 19 23 (4) (a), (c) (v), (d) and (e) 29/04/05 29. 30. 31. 32. 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 OP27 Good Practice Recommendations It is recommended that the registered providers review the staffing of the home with a view to appointing a deputy manager or possibly two senior care workers to ensure that there is always a senior member of staff on duty seven days a week on the early and late shifts and continuity of responsibility in the absence of the registered providers. 2. St CATHERINES HOME Version 1.00 Page 29 Commission for Social Care Inspection 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 © 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 HOME Version 1.00 Page 30 - 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!