Inspection on 06/06/05 for St Catherine`s House Nursing Home

This inspection was carried out on 6th June 2005.

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

The inspector 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 10/07/06

St Catherine`s House Nursing Home 06/02/06

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 CATHERINES HOUSE NURSING HOME 23a Kensington Square LONDON W8 5HN Lead Inspector Sheila Lycholit Unannounced 6 June 2005 at 10:15 AM 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 HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Catherines House Nursing Home Address 23a Kensington Square, London W8 5HN 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 7937 9688 020 7361 4757 The Trustees of the Congregation of the Religious of the Assumption Mrs Violet Ilagan Care Home 14 Category(ies) of Physical disability (14) registration, with number of places ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 February 2005 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 accomodation 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 CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 5 hours from 10.15AM until 3.15PM. The Community Superior made herself available throughout the visit. The Nurse Manager met the Inspector in the morning to discuss changes recently implemented before leaving to attend a pre-arranged training session. In addition to the Community Superior and Manager there were 2 staff on duty, a Registered Nurse and a Care Assistant. The Chef Manager and Domestic Assistant were also working in the home. There were 10 residents at the time of the inspection, 9 of whom were Sisters and one a lay person. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 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 HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 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 Sisters considering a move to St Catherine’s House are normally very familiar with the home having lived in the adjacent main house, nevertheless they are given a considerable period, often several months, in which to decide whether the move is the right choice for them. Where assessments are not undertaken by Social Services Care Managers, the home’s staff have comprehensive assessment procedures in place. EVIDENCE: The home has a Statement of Purpose and Guide, which are reviewed annually. Each of the 5 residents’ files seen contained an assessment carried out by the Nurse Manager, including a dependency assessment and Waterlow score, from which a care plan using the Activities of Daily Living format was drawn up. Records show that other professionals, such as Physiotherapists and OTs, are asked to contribute to assessments. Staff receive regular training in the care of older people and have access to specialist advice and services such as the Dementia Care Team. No new residents have been admitted since the last inspection in February this year. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 8 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 and 10 Care plans are comprehensive and up to date. The health care needs of residents are carefully monitored. Staff ensure that residents have access to a range of health services and the home is well supported by the local GP practice. The Nurse Manager takes steps to ensure that good practice in the administration of medication is promoted. Sisters of the Order and senior staff create an atmosphere of respect and concern for residents. EVIDENCE: Residents’ files show that recording has improved since the last inspection, with more detailed care plans and daily notes, including the notes written by night staff. Detailed risk assessments were available on each of the 5 files seen. Handover notes contain relevant information for staff, which is also discussed verbally. The Nurse Manager has produced clear ‘at a glance’ notes for new staff, including agency staff. Service users’ weight is monitored and action taken. Action is taken to prevent skin breakdown. Referrals are made to health care services including dental services, Opticians and the Hearing Aid Clinic. The multi–professional records on residents’ files show that health care staff regularly visit residents at the home. An Optician visited the home during the inspection. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 9 The Boots measured dosage system is used for medication, which is stored in a locked room. The most recent report by the Boots Pharmacist was in September 2004. This report is satisfactory. The Nurse Manager monitors the administration of medication and notes all errors, usually gaps on the MAR sheet, at the front of the file. These errors are discussed with the individual Nurse and reviewed at the staff meeting. Three residents hold their own medication, following an assessment by the GP. Standard 11, care and comfort to service users who are dying, was not looked at during this inspection. This standard was exceeded at the previous visit in February 2005. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Residents are supported to continue to follow the religious life that they previously led, including taking part in prayers, Mass and community meetings. Families and friends visit regularly and good links are maintained with the local community. EVIDENCE: Each resident’s file contains a daily plan drawn up with the individual, setting out her routine, including times of getting up and going to bed. There are facilities for families and friends to stay overnight if they wish and arrangements are also made for residents to stay with their families, as well as to go on retreat. The home was taking part in the London garden squares event on the Sunday following the inspection, during which a considerable number of visitors were anticipated. The Chef Manager was on duty during the inspection visit. Catering is provided by an external contractor, under a long-standing arrangement that meets the needs of the home. The Inspector sampled the meal at lunch tome, which was well-prepared and presented. Meals are taken in the dining room, where members of the Order take care of residents. The lay resident, who needs help with eating, has her meal in the sitting room on the first floor. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 11 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) 16,17 and 18 The home has a clear complaints procedure, with a senior member of the Order investigating any complaint. The adult protection procedure for the Order’s services has been revised and updated. St Catherine’s policies on whistle-blowing and bullying have been revised and re-issued in the staff handbook. Action identified following an investigation earlier this year has been implemented. EVIDENCE: As noted above, policies and procedures have recently been reviewed and the monitoring of staff performance enhanced. Discussion with the community Superior and records of staff meetings show that the new staff handbook and revised policies have been discussed with staff. Staff have undertaken refresher training in moving and handling, which was an area of concern raised. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,21,22,23,24,25 and 26 The building, which is well maintained, has been adapted to a high standard to both meet the needs of older people and the way of life of the religious community. The building and very attractive gardens are accessible for wheel chair users and specialist equipment has been installed where needed for individual residents. The facilities available are regularly reviewed. Steps are taken to ensure the health and safety of residents and staff. EVIDENCE: All bedrooms are single rooms with an en suite lavatory and washbasin. Bedrooms have views over the communal gardens or the private garden and are bright and airy. Windows are low enough for residents to see out when sitting down and the lighting is well designed. Communal areas are spacious and furnished in keeping with the needs of residents and design of the building. The domestic assistant was present during the inspection. The home was cleaned to a high standard. Since the last inspection the need for additional security to the entrance has been identified and the main doors are now opened externally from the office. Although spacious, the home does not have sufficient storage for large ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 13 equipment and some changes to the building are planned which will provide an additional storage area. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 14 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) 27,28,29 and 30 Staffing levels meet the needs of the current residents and are augmented by the Sisters of the Order who assist in the home. Recruitment of staff follows a sound recruitment procedure and all staff, including bank staff, are subject to a probationary assessment. Staff training is given a high priority and a programme of accredited training for staff has ensured that the majority of care staff have achieved at least NVQ2. EVIDENCE: Rotas show that 1 RGN and 1 Care Assistant are on duty on each shift. In addition 4 Sisters of the Order live and work in the home, helping with management, finance, and housekeeping, as well as assisting residents. Three of the 10 current residents are largely self-caring. One member of staff, a RGN, has been recruited since the last inspection. She confirmed that her induction covered all the information that she needed and that she felt supported in her post. In addition to NVQ training, staff have attended workshops on vascular dementia, tissue viability, infection control, risk assessments and moving and handling. No agency staff are currently employed. The Nurse Manager confirmed that confirmation of references and CRB checks would be required in writing before an agency member of staff began working at the home. Staff have been issued with a new handbook. Copies of the NMC and GSCC codes of practice are available on the policies and procedures file kept on the staff desk. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 15 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) 31,32,33,35,37 and 38 The Nurse Manager, Community Superior and senior members of the Order ensure that that the home is well managed and that the Sisters and lay residents are cared for in line with the Order’s principles and philosophy. EVIDENCE: The Nurse Manager has many years experience in caring for older people and has completed the Registered Manager’s Award. She is supported by the community superior, who is currently responsible for a number of aspects of the overall management of the home. Both the Nurse Manager and Community Superior are NVQ Assessors. The Order has been reviewing the management structure of the home with a view to the long term future of the service. An overall lay Manager has been appointed who will take up her post next month. Some aspects of finance and maintenance for the home have been transferred to the Maria Assumpta Centre, which is on site. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 16 The finances of the residents who are Sisters are managed by the Order. The lay resident’s finances are managed by members of her family, who have power of attorney A more formal quality assurance system is being introduced, which had been discussed with residents at a community meeting the day before the inspection. Supervision records were not seen at this inspection. In discussion the Community Superior and Nurse Manager discussed the ways in which the performance of staff was being more formally monitored. Records seen were detailed and well written. In view of the number of care staff who have completed at least NVQ2, it is recommended that ways of enabling them to contribute to care planning and daily notes be explored. In particular the Senior Care Assistant who has achieved NVQ3, should have opportunities to take part in record keeping. Responsibility for health and safety is shared with the Health and Safety manager of the overall site. The Health and Safety policy is available on the staff desk. Accidents are well recorded, with only one accident occurring since the previous inspection in February. The risk assessment had been revised following this accident- a fall in which the resident suffered no injury. Security at the entrance to the home has been improved. Fire records were looked at and were up to date. The kitchen was clean and a problem with the cool room was being managed satisfactorily. There had been no visit by the EWO since the last inspection. Staff receive Health and Safety training as part of their induction. As noted above, refresher training is regularly provided. A terry towel is provided in the staff lavatory on the first floor. This was freshly laundered but it is recommended that disposable towels or hand-driers be provided to reduce the risk of cross infection. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 x 3 3 ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 18 No 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 Regulation Requirement Timescale for action 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. 3. Refer to Standard 37 38 38 Good Practice Recommendations Ways of supporting care staff to contribute to care planning and recording should be explored. Any bin used to dispose of food eg. in the kitchenettes, should have a lid. All hand-washing areas used by staff should have disposable towels/hand-driers to prevent cross infection. ST CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 19 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 CATHERINES HOUSE NURSING HOME G60-G09 S26017 ST CATHERINES NH UIV223824 170505 STAGE 4.doc Version 1.30 Page 20 - 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. 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