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Inspection on 06/08/08 for St Catherine`s Nursing Home

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

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Relatives feel that the residents are well looked after and they made the following comments: "The staff are very kind". "The staff are very good. They take time to talk to the residents". "My Mother is well cared for". Staff are quick to seek advice and treatment when a resident starts to lose weight. The staff make sure that the residents are clean, comfortable and well dressed. In order to protect the residents from harm, management make sure that they check people out properly and safely before offering them a job. Management make sure that the staff are properly trained so that they have the knowledge and skills they need to protect and meet the needs of the residents. Management are good at checking out the quality of care and the services provided for the residents.

What has improved since the last inspection?

The care plans now contain a lot more information about how the residents are to be cared for. The timing of the serving of meals has changed, mainly on the Dementia unit Mealtimes are less hurried and the residents are eating better and enjoying their food. We found improvements in the recording and general organisation of the medicines. Records of medicines received, administered and disposed of were usually clear and accurate. The environment continues to be improved, especially on the Dementia Unit. New flooring has been laid in bathrooms and toilets and furniture is gradually being replaced in the bedrooms.

What the care home could do better:

To ensure that the needs of the residents are met, more attention must be given to ensuring that the risk assessments are regularly reviewed. Medicines must be given to people correctly because receiving medicines at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. Further review and updating of peoples` care plans should be made to help make sure `when required` medicines are handled safely.

CARE HOMES FOR OLDER PEOPLE St Catherine`s Nursing Home Queen Street Horwich Bolton Lancashire BL6 5QU Lead Inspector Grace Tarney Unannounced Inspection 6th August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherine`s Nursing Home DS0000005697.V368956.R04.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 Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherine`s Nursing Home Address Queen Street Horwich Bolton Lancashire BL6 5QU 01204 668744 01204 668727 st.catherines@fshc.co.uk 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) Tameng Care Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Care Home 61 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability (1) St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 61 service users to include:Up to 30 service users in the category of DE(E) (Dementia over 65 years of age) Up to 30 service users in the category OP (Old age not falling within any other category) Within these numbers Nursing care can be provided for up to 30 service users One named service user in the category PD (Physical Disability) The registration to revert to the original respective categories should the named service user leave the home. 2nd April 2008 2. Date of last inspection Brief Description of the Service: St. Catherines is a purpose built Home with accommodation on the ground and first floors. The home is situated within walking distance of Horwich Town Centre and the local shops. It is close to a main bus route and not too far from the motorway network. Car parking is provided to the front of the home and garden space is provided to the sides and rear. The home is registered to provide accommodation to 61 residents and offers nursing and personal care services. However, because the two double rooms are now used only as single rooms, the maximum number of services users at any one time is reduced to 60. There is a dedicated dementia care unit. All rooms are for single occupancy; one room has en-suite facilities. This unit has its’ own lounges and dining room. The bedrooms on the first floor are for the nursing and residential residents and are reached either by stairs or a passenger lift. There is a lounge and dining room on the first floor and lounges and dining rooms on the ground floor for both the Residential and Dementia Units. Most of the toilets and bathrooms have aids to assist any resident with a disability or mobility problem. The provider informed the inspector that the fees within the home ranged from £358.68 to £597.00 per week. The fees payable depend on the care being provided. Additional charges are made for private chiropody, hairdressing and newspapers. This information was received on the 6/08/08. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The home was not told that this inspection was to take place although many weeks before the inspection, we (The Commission) chose some residents to send questionnaires (comment cards) out to. The questionnaires asked what people thought about the care and quality of the service provided. Only 1 questionnaire was returned. We were told that this resident was happy with the care and facilities provided. Also before the inspection we asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they did at present, what they felt they did well and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way we do. The site visit by an inspector and a pharmacy inspector took place over 8 hours. During this time we examined care and medicine records and care practice to make sure that the health and care needs of the residents were being met. We also looked around the at some of the bedrooms, bathrooms, toilets and sitting areas to check if they were clean, warm and well decorated. We also looked at the menus and the meals served throughout the day. We also checked how many staff were provided on each shift to make sure the residents’ needs were being met, and also looked at how the staff are trained so that the staff can do their jobs properly. We also checked to see that staff were safely recruited so that the residents are protected from being cared for by unsuitable people. We also looked at how management check that the care and services that they provide is what the residents and their relatives want, or expect. How the home manages the residents’ spending money was also looked at. In order to get further information about the home we also spent time speaking to 1 resident, 3 relatives, 2 care staff and the cook. What the service does well: Relatives feel that the residents are well looked after and they made the following comments: “The staff are very kind”. “The staff are very good. They take time to talk to the residents”. “My Mother is well cared for”. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 6 Staff are quick to seek advice and treatment when a resident starts to lose weight. The staff make sure that the residents are clean, comfortable and well dressed. In order to protect the residents from harm, management make sure that they check people out properly and safely before offering them a job. Management make sure that the staff are properly trained so that they have the knowledge and skills they need to protect and meet the needs of the residents. Management are good at checking out the quality of care and the services provided for the residents. 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 St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 8 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 Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are properly assessed before they are admitted to the home and this gives an assurance to everybody that a person is only admitted if the staff can meet their needs. EVIDENCE: An assessment looks at what help and support the prospective resident needs in all aspects of daily life. There had been no new admissions to the home since the last inspection so therefore Standard 3 was not inspected in detail during this visit. During previous inspection visits we have seen that a very detailed assessment document was in use and that the Standard has continually been met. We saw assessments in place in the care plans that we looked at. Standard 6 does not apply. The home does not provide Intermediate Care St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 &10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans show what care needs the residents have and how they are to be looked after. There have been some improvements in the checking and recording of medicines. Some medicines however were being missed or given at the wrong time. This puts the health and well being of the residents at unnecessary risk. EVIDENCE: Individual care plans were in place for each resident. The care plans of 5 of the residents were looked at, 3 on the Dementia Unit and 2 on the Nursing Unit. The care plans were detailed and gave enough information to show what the residents needs were and how the residents were to be looked after. The care plans were looked at regularly to report any changes that may have occurred and then updated where necessary. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 11 3 of the residents had lots of nursing needs so we visited them in their bedrooms. They looked comfortable and well cared for and all the correct type of equipment was in place to ensure that their needs were met. One of the residents told us that she was looked after very well. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores, any risk of falling and also if they were at risk due to problems with their diet and fluid intake. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. These risks were looked at regularly. Staff also assessed the condition of a residents’ mouth and looked at any problems or potential problems that they may have. They also assessed the residents’ ability in relation to continence. These however were not reviewed as regularly as they should have been. It was not very clear from the documents looked at how often they were to be reviewed. Some had not been done for several months. So that any changing needs of the residents can be identified and acted upon, assessments must be reviewed regularly. Residents were weighed regularly and staff were quick to seek advice and treatment when a resident was starting to lose weight. We saw evidence of referrals to their GP and treatments prescribed by visiting dieticians. We spoke to 3 relatives during our visit that told us the following: “The staff are smashing”. “I cannot fault them”. “Like anything else, some staff are better than others”. As part of the visit a specialist pharmacist inspector looked at how medicines were handled because a previous pharmacist inspection had found serious mistakes in medicines handling. We looked at a sample of medicines stocks, medicines records and care plans in all three units. We found significant improvements in the recording and general organisation of the medicines. Records of medicines receipt, administration and disposal were usually clear and accurate helped by improved checking and auditing by managers. This is a significant improvement from the last visit that made accounting for medicines much simpler. We looked in detail at how medicines in bottles and packets were given and found one example of a liquid medicine used for depression being missed for the last nine days. We also found it difficult to account for all liquid medicines, particularly in the dementia unit, because sometimes there were two bottles of St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 12 the same medicine being used. We looked at a sample of records from the previous month and found some examples of medicines being ‘out of stock’. The acting manager said that a meeting with the community pharmacist had highlighted this problem and that action had been taken to help prevent this happening again. Going without prescribed medicines could harm the health and wellbeing of people who live in the home. We looked at the times medicines were given and found they were not always given at the correct and best time for individuals. Some medicines used for bone problems were given after food instead of before for three different people. Taking medicines at the wrong time can stop them working properly and cause unnecessary side effects, which could affect the health and wellbeing of the person taking them. We looked at how ‘when required’ medicines were being used. Care plans had now been developed for most of these but we still found some lacked enough detail to help make sure they were given correctly. One person that was prescribed ‘when required’ pain relief and a medicine for agitation did not have a clear written care plan for this, which could lead to the wrong medicine being given. Having detailed care plans helps make sure people get their medicines when they need them. We looked at how medicines were stored and found the trolleys, rooms and cupboards to be clean, tidy and secure, this helps make sure medicines are kept safe. We looked at the arrangements for handling controlled drugs (medicines that can be misused). Special registers were used for making records and a controlled drug cupboard was used for storage. We found improvements in how these medicines were being handled and found staff were now giving and recording them correctly. Having suitable arrangements for controlled drugs helps keep them safe. The residents looked clean and comfortable and were suitably dressed. Their hair was neat and tidy and clothes were clean and ironed. Staff spoke to them in a respectful and quiet way, although there was plenty of friendly banter. Staff confirmed that the importance of ensuring privacy, respect and dignity is part of their initial training. We were escorted around the Dementia Unit by the activities organiser. He made sure that he knocked on bathroom, toilet and bedroom doors and waited for a response, before entering. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice and control over their lives as far as they are able and enjoy the activities available to them. Residents are given a choice of well-balanced and nutritional meals. EVIDENCE: The residents’ routines of daily living, such as when they like to go to bed and when they usually get up, plus their social interests were recorded in their care plans. An activity co-ordinator is employed full time and a programme of activities and events, was displayed in the reception area. We saw a group of residents on the Dementia Unit enjoying a craft activity. A visiting relative told us that some of the residents had been on several trips out as they have had the Company mini bus for the last two weeks. We saw relatives coming and going throughout the day and they seemed to know the staff very well. One relative told us that they are always made welcome and are able to visit at any reasonable time. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 14 We did not eat with the residents but watched what they were having for breakfast on the Dementia Unit and what the residents were having for lunch on the Nursing Unit. We were told that the timing of the serving of meals on the Dementia Unit has changed. Residents have tea and toast when they get up and then breakfast is served between 9.30am and 10am when most of the residents are up and dressed. Lunch is served at about 1.30pm and the evening meal served about 5.30pm. This means that mealtimes are less hurried and fit in with the residents’ routines rather than the other way round. Staff told us that the residents are eating better and enjoying their food. We were also told that a lot more “finger food” is now provided. This means that if residents do not want to sit down they can still wander about or sit away from the table and they will still be receiving nutritious meals. Staff told us that this new system was working well. The meals served were home cooked and looked appetising and nutritious. The residents have a choice of food at breakfast, lunch and teatime. Fresh fruit was available and hot and cold drinks were served throughout the day. Any cultural or dietary needs, likes and dislikes were looked at when a resident is first admitted to the home. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel able and know how to complain, and staff have a good knowledge and understanding of what abuse is, thereby reducing the possible risk of harm to residents EVIDENCE: A detailed complaints procedure was in place and was displayed in the reception area. The complaints procedure was also included in the Service User Guide. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. A record is kept of any complaint made and includes details of the investigation and any action taken. No complaints have been made to us since the last inspection of April 2nd 2008. A discussion with the some of the care staff showed that they were very aware of the procedure to follow in the event of any allegation of abuse. All the staff have undertaken training in the protection of vulnerable adults. Management also confirmed this in the AQAA form that was sent to us. Records of training were kept on the training file. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in suitably adapted, comfortable surroundings that are continually being improved. EVIDENCE: We looked at the lounges, dining areas, bathrooms and toilets on each unit. We also looked at some of the bedrooms on each floor. The Dementia Unit has a large, secure and well-kept patio/garden that is accessible to residents. The residents have the use of any of the two lounges, a conservatory and the large dining room. Grab rails to aid mobility are in place along the corridor walls. The corridors were bright and nicely decorated. Each corridor on the Dementia Unit has themed decorations such as beach, sport, cookery and music. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 17 The lounges/dining rooms were clean and warm. The dining room upstairs had new flooring and new furniture and looked a very pleasant room. The carpet in the upstairs lounge however, was stained. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were close by to bedrooms and lounge areas and most had aids and adaptations to assist the residents. Apart from 1 shower room all the bathrooms and toilets had been recently refitted with new non-slip flooring. This made them look a lot cleaner and brighter. There has been a rolling programme of redecoration and refurbishment of the bedrooms. Several had new furniture and had been decorated to a good standard. Management were told that they need to give priority to decorating one of the bedrooms on the Dementia Unit and one of bedrooms on the Nursing Unit. These were in a poor condition. Hand washing facilities to reduce the spread of infection, were in place in bedrooms, bathrooms and toilets. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by staff that are suitably trained and safely recruited. EVIDENCE: Inspection of the duty rotas for each unit and a discussion with staff and relatives showed that they felt there was enough staff on duty over a 24-hour period to meet the needs of the residents living at the home. 1 staff member felt that at times however, the Dementia Unit would benefit from a further qualified nurse, certainly between the hours of 8am –2pm. This was discussed with the acting manager who stated that this would be kept under review. The information from the AQAA document sent to us, and the information that we looked at in the training file showed that 51 of the staff had obtained their NVQ level 2 or above in care. The personnel file of 1 staff member was inspected. This was in order and showed that the staff member had been properly and safely employed. Induction training is provided for all newly employed staff. This is to make sure that they understand what is expected of them and that people are cared for properly and safely. We also saw evidence of further training that had been undertaken. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 19 Training in moving and handling and the protection of vulnerable adults had been undertaken by all of the staff. In addition training in basic food hygiene, first aid, health and safety, fire safety, care planning, infection control and other relevant topics had been undertaken or had been arranged. 9 staff members from the Dementia Unit had recently undertaken training in the management of Challenging Behaviour. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and presently well managed. Management continually look at the care and facilities they provide so that the residents’ welfare is protected. EVIDENCE: The home does not yet have a manager who is registered with us. A temporary manager is presently managing the home. She is a qualified nurse with several years experience of caring for the elderly and she has a management qualification. She has worked for the company for over 5 years in a senior position. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 21 Visitors told us that they trusted her. They told us that they felt that she would put things right if they had a problem. Staff also told us that she was strict but fair and knew what she was doing. Information from the AQAA document sent to us and documents looked at in the home showed that management do a monthly check of lots of things in the home. They check to make sure that there are no hazards around the building and also check the records about care, medicines, food and any accidents that have happened. They also send out surveys to residents and relatives asking for their views on the services provided. They also hold resident/relative meetings every 4 months. The manager told us in the AQAA document that she has an Open Door Policy. The systems in place for the management of residents’ money were good. We were told that they only handle money brought in for the residents’ expenses. Receipts were given out and copies retained for all financial transactions. Information received from the Annual Quality Assurance Assessment document showed that the equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. We were told that there is regular weekly checking and testing of fire detection system, fire exits and emergency lights. We were not able to see evidence of this however as the person responsible for this told us that he kept the log book at home so that it did not get lost. Management were advised to make sure that the logbook was returned to the home the following day. The records of fire security checks must always be available for inspection by the relevant authorities. St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 3 3 3 x x 2 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 2 x 3 x 3 x x 2 St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 15(2)(a) Requirement So that any changing needs of the residents can be identified and acted upon risk assessments must be reviewed regularly. Medicines must be given to residents as prescribed because receiving medicines at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. (Previous requirement of 3/04/08 not fully met. Whilst the requirement in relation to certain medicines from the last inspection was met staff had either given other medicines out at the wrong times or not given them for several days. ) The bedrooms identified on inspection must be redecorated to an acceptable standard The fire logbook must always be available for inspection. Timescale for action 11/08/08 2 OP9 13(2) 06/08/08 3 4 OP24 OP38 23(2)(d) 17(2) 30/11/08 07/08/08 St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Further review and updating of peoples’ care plans should be made to help make sure ‘when required’ medicines are handled safely St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Catherine`s Nursing Home DS0000005697.V368956.R04.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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