Inspection on 10/07/06 for St Catherine`s House Nursing Home

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 House Nursing Home 06/02/06

St Catherine`s House Nursing Home 06/06/05

St Catherine`s House Nursing Home 07/02/05

St Catherine`s House Nursing Home 05/07/04

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

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

CARE HOMES FOR OLDER PEOPLE St Catherine`s House Nursing Home 23a Kensington Square London W8 5HN Lead Inspector Sheila Lycholit Unannounced Inspection 10th July 2006 10:35 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 House Nursing Home DS0000026017.V298774.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 House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherine`s House Nursing Home Address 23a Kensington Square London W8 5HN 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 7937 9688 020 7361 4757 The Trustees of the Congregation of the Religious of the Assumption Care Home 14 Category(ies) of Physical disability (14) registration, with number of places St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: St Catherines House is a 14 place Care Home with Nursing, which provides care and support for older Sisters of the Order of the Religious Assumption in a setting where they can continue to be part of the religious community. On occasions lay people needing care may be admitted. The accommodation is in a modern, well-adapted building over 3 floors. It overlooks a large garden square shared with other services on the Maria Assumpta site. The home also has its own private garden. All bedrooms are single rooms with en suite facilities. The building has a lift and is accessible for wheel chair use. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit took place on Monday 10th July 2006 from 10.35AM until 3.20PM. The Manager was on duty with 1 RGN and 1 Health Care Assistant. The Community Superior was working on site and another Sister was also helping in the office. The Cook and domestic assistant were also on duty. There were 9 service users resident in the home, 8 of whom were Sisters of the Order and 1 a lay person. The Manager, who made herself available throughout the visit, had completed a pre-inspection questionnaire. The Inspector spoke with the 2 members of staff on duty and met with residents during a tour of the building. Six comment cards were received from service users, 3 from relatives and 6 from visiting health and social care professionals. All of the comments received were positive about the care provided at St Catherine’s House. What the service does well: What has improved since the last inspection? What they could do better: The Manager must have oversight of contracts and records relating to health and safety, including fire safety, so that she can ensure the health and safety of service users and of staff. St Catherine`s House Nursing Home DS0000026017.V298774.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. St Catherine`s House Nursing Home DS0000026017.V298774.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 House Nursing Home DS0000026017.V298774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 The quality of outcomes for these standards is good. A sound assessment procedure is available, which is regularly reviewed. The staff team has the necessary skills to provide good care. Staff have well established links with multi- professional colleagues who can provide specialist advice. EVIDENCE: The Manager confirmed that no changes have been made to the Statement of Purpose and Service User’s Guide. Copies of the most recent inspection report are available in the office and at the desk used by staff on the first floor. No new admissions to the home have taken place in the past 12 months. Four residents’ files were looked at. These showed that staff regularly re-assess each service user using standard tools. Similar assessments would be undertaken for new residents. Although most new residents are familiar with St Catherine’s as they have lived in the adjacent building, the initial stay at the home provides an opportunity for the person to assess whether the move meets their needs. Last year one Sister returned to the main convent as she felt that she no longer needed the care provided at St Catherine’s. St Catherine`s House Nursing Home DS0000026017.V298774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality of outcomes for these standards is excellent. A high standard of care planning has been developed. Residents have access to a range of health care services and health concerns are promptly followed up. Policies and procedures are in place, including a monthly audit, to ensure that good practice is followed in the administration of medication. Senior staff promote an atmosphere of respect and concern for residents. EVIDENCE: The Manager has continued the work of the previous Manager in developing care plans, which are now of a high standard. The care plans of the 4 frailest residents were looked at, each of which was in good order. Comprehensive care plans have been drawn up, which are regularly reviewed by the key worker. Records show that the Manager regularly checks care plans to ensure that re-assessments and reviews are recorded and are up to date. Daily notes are cross-referenced to the core care plan. The Manager has been supporting Health Care Assistants to contribute to care planning, as recommended at the last inspection. In discussion, a Health Care Assistant said that she found that the sessions about care planning had given her more confidence and had been helpful. All risk assessments seen were up to date and showed that action had been taken following an accident, incident or deterioration in a resident’s condition. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 10 Discussion with the Manager, records and feedback show that a high priority is given to residents’ health care needs. All appointments are recorded on a monitoring sheet and the outcome noted on the file. A wide range of local services is used. Feedback from the local GP was very positive about the attention given to residents’ medical needs and the communication skills of senior staff. A visit to the medicines’ room showed that it has been re-organised and new locks fitted to cupboards. The Manager has introduced a monthly audit of drugs administration. A copy of the June audit showed that all aspects of administration were satisfactory. MAR sheets seen were fully completed. Two residents currently handle their own medication following an assessment. Staff were observed to treat residents courteously and to respond promptly to calls for attention. There have been no deaths at the home since the last inspection. The care of residents who are at the end of their lives has been assessed as excellent at previous visits. St Catherine`s House Nursing Home DS0000026017.V298774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality of outcomes for these standards is good. Sisters who are residents are able to follow the religious life that they have chosen, with attendance at Mass, prayers and community meetings. Good links are maintained with families and friends and with the local community. Concerns, identified by senior staff, about some aspects of catering have been addressed. EVIDENCE: Daily routines are drawn up with each resident and are recorded on file using a schedule. Records show that routines are changed and adapted to the resident’s condition. With the exception of the resident who is not a member of the Order, Sisters’ daily routines centre around the religious community. Accommodation is available for families and friends to stay overnight. Feedback was received from 3 families, which showed that they were very happy with their relatives’ care. Residents have their main meals in the pleasant dining room. The Community Superior has introduced a system of Sisters serving themselves from a heated trolley, except for the most frail who are served at the table or in their rooms. Food is cooked on site from fresh ingredients. Senior staff identified that some food served did not meet the nutritional needs of the frailest residents and steps have been taken, including changes in the catering arrangements, to ensure a more flexible and responsive approach. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 12 St Catherine`s House Nursing Home DS0000026017.V298774.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The quality of outcomes for these standards is good. There is a clear complaints policy, which was revised in August 2005. Systems are in place to protect residents and to promote their welfare. EVIDENCE: No complaints have been received since the last inspection. The staff handbook was re-issued in 2005 and included new policies on whistle –blowing and bullying. A programme of staff training in adult protection issues has continued throughout this year. Action has been taken to address staff performance, in particular where poor performance was affecting residents’ care. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The quality of outcomes for these standards is excellent. Residents live in an attractive and well-adapted building, which is fully accessible for wheel-chair users. The need for any additional specialist equipment is regularly assessed. EVIDENCE: All bedrooms are single rooms, with an en suite lavatory and washbasin. The windows, which allow residents to see into the garden from a chair or bed, have been recently replaced and secondary glazing installed. There are a number of communal rooms, which are well-furnished including a sitting room, activities room and chapel. There is wheel-chair access to the very well kept gardens that are maintained by a Sister of the Order. Comments from residents show that they get great pleasure from the garden and the wildlife that it attracts. There is a lift to all floors. The building is well supplied with bathrooms and lavatories, some of which include specialist equipment. A new shower and mobile hoist have been purchased this year. There is insufficient storage space for equipment. The creation of a storage room on the ground floor is being considered. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 15 The building is generally in a good state of repair and decoration. The Manager and community superior have undertaken a review of the building and identified areas that need attention. Improvements to the kitchenette and redecoration of some areas had been agreed and work was to start later that week. The front door is kept secure, with access via an entry-phone. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality of outcomes for these standards is good. Staffing levels meet the needs of the current residents. A sound recruitment and appointment procedure is in place and staff development and training is given a high priority. EVIDENCE: Staffing rotas allow for 1 RN and 1 Health Care Assistant to be on duty on each shift, including nights. Additional support is proved by the Community Superior and by other Sisters who carry out administrative tasks, take telephone calls and assist residents. The Manager assesses that of the current 9 residents, 2 have high needs, 5 have medium needs and 2 have low needs. Of the 6 Health Care Assistants, 4 have achieved NVQ Level 2 or above. During the past 12 months 4 staff have left, including the Manager. The personnel files of 2 staff were looked at, including the most recently appointed staff member. Both files were in good order, showing that all checks had been carried out. The Manager has successfully re-organised the staff files since her appointment. There is a comprehensive staff training and development plan based on the needs of the service, which includes skills updates for RNs, dementia care, adult protection and nutrition. The Manager has used the monthly team meetings as training sessions to ensure that all staff are up to date in various areas of practice and are adopting a consistent approach. Both staff spoken with commented on the amount of training provided and on its high quality. New staff receive a structured induction to St Catherine’s, with new Health Care assistants using the Skills for Care Induction and Foundation training St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 17 workbook. All staff undertake basic training, including refresher training and First Aid. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 The quality of outcomes for these standards is good. Although St Catherine’s has experienced a number of management changes over the past year, these changes have not been to the detriment of the care of service users. The current Manager, supported by the new Community Superior, has continued to develop the service and to further raise standards of care and to improve the running of the home. Members of the Management Committee now visit the home monthly and produce a detailed report. Record keeping is generally good. The Manager must have oversight of health and safety contracts and records, some of which were not available on the day of the inspection. EVIDENCE: The Manager who has been in post since February, is a Registered Nurse with many years experience in providing services for older people. She has taken steps to develop a more cohesive staff team, to improve communication and to introduce a consistent approach in the care of residents. The Manager has seen staff regularly on a one to basis to discuss their professional development St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 19 And to resolve long-standing communication problems. The Manager has been supported by the Community Superior, who is also new to St Catherine’s. Both attend the Management Committee. Members of the Management Committee visit the home monthly and produce detailed reports, copies of which are forwarded to the CSCI. The Manager is looking at ways of introducing quality monitoring. A format has been developed for use at St Catherine’s but has not been implemented. The personal finances of Sisters are managed by the Community Bursar. The finances of the lay resident are managed by her family. Accidents are carefully recorded, with preventative action taken. There have been 7 accidents since the last inspection in February, most of which were falls. St Catherine’s has been part of a falls monitoring project carried out by the PCT and staff have received training in falls prevention from the Nurse Consultant. Training records show that all staff have undertaken training in health and safety, including refresher training. Staff received training in fire safety and the use of fire extinguishers in April this year. Fire points are checked weekly. Previous records showed that the fire detection system is serviced 4 times a year, though records for 2006 were not available. The water quality is checked twice yearly and the water temperature is taken monthly and any adjustments made by an external company. The records of hot water checks were only available until March 2006. A schedule of planned maintenance checks for the year is available. The Manager must have access to all health and safety records and contracts so that she can ensure the safety of residents and staff. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 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 3 17 x 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 3 3 1 St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13, 23 Requirement The Manager must have access to contracts and records relating to health and safety within the home. Timescale for action 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations Quality assurance systems should be further developed and an annual report published. St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Catherine`s House Nursing Home DS0000026017.V298774.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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