Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 08/06/07 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 8th June 2007.

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 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 manager makes sure that the home only cares for those people whose needs the staff can meet. A safe system is in place for managing the medicines. The Company is making sure that the staff are properly trained.

What has improved since the last inspection?

A new manager has been employed and staff feel that things are now getting better. More attention is now given to making sure that the residents` privacy and dignity is respected. Locks have now been fitted to all toilet and bathroom doors. New furniture and bed linen has been provided. Management are actively recruiting new nursing and care staff, particularly for the Dementia Unit. Most of the things that needed doing from the last inspection have been done.

What the care home could do better:

Staff must make sure that they keep the records of the residents` care needs up to date. Staff must make sure that they look at anything that may be a risk to the resident and write down in the residents record when they have done this, and what action they have taken to reduce the risk. They must keep these risk assessments up to date. The home must provide a choice of food that is nutritious and adequate and suitable for the varying needs of the residents, particularly on the Dementia Unit. The programme of redecoration and refurnishing needs to continue so that the residents can live in a comfortable and pleasant environment.

CARE HOMES FOR OLDER PEOPLE St Catherine`s Nursing Home Queen Street Horwich Bolton Lancashire BL6 5QU Lead Inspector Grace Tarney Unannounced Inspection 8th June 2007 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.V334480.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 Nursing Home DS0000005697.V334480.R01.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.V334480.R01.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. 23rd January 2007 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 a lounge and dining room on the ground floor that is for the residential residents. 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 £349.93 to 391.41 per week for those residents funded by local authorities and £414.00 to £472.00 for private residents who pay for their own care Additional charges are made for private chiropody, hairdressing and newspapers. This information was received on the 8th June 2007. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection questionnaires called Have Your Say were sent out to the residents and their relatives. These questionnaires asked what people thought of the quality of the service and the facilities provided. Only two were returned. These were from relatives. What they felt about the care and services provided is written in different sections throughout this report. Two Inspectors visited the home and were there for 9 1/2 hours. For this inspection they concentrated on the Dementia Unit. They looked at care and medicine records to ensure that the health and care needs of the residents were being met. They also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit their staff. 1 Inspector looked around the unit at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. The Inspectors also looked at the food stocks and what the residents were having for their lunch and evening meal. In order to get further information about the home the Inspectors also spent time speaking to one relative, a visiting GP, five care staff (two were agency carers), a qualified nurse, the manager, the cooks and the activities organiser. What the service does well: The manager makes sure that the home only cares for those people whose needs the staff can meet. A safe system is in place for managing the medicines. The Company is making sure that the staff are properly trained. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Catherine`s Nursing Home DS0000005697.V334480.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 Nursing Home DS0000005697.V334480.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. 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 home can meet their needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The pre-admission assessment records for five residents were inspected on the Dementia Unit. All five residents had undergone a detailed pre-admission assessment that was conducted by a senior nurse employed at the home. This assessment looks at what help and support the prospective resident needs in all aspects of daily life – including their mental health needs. The preadmission assessment documentation is supplemented by a dependency assessment-rating tool and takes a more in depth look at particular areas of need/support. The pre-admission assessment completed by the home was also supported by assessments carried out by social workers and/or health St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 9 care professionals who had come to the conclusion the prospective resident required dementia nursing care. Standard 6 does not apply. The home does not provide intermediate care. St Catherine`s Nursing Home DS0000005697.V334480.R01.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. Although the care plans are not as up to date as they could be, the care practices ensure the safety and well being of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The care records of five residents were inspected in detail on the Dementia Unit. Three of them contained detailed information to show how they were to be cared for. Their care records were organised in a standard format – although it was the case that some information recorded elsewhere had not been transferred to the care records. All contained detailed pre and post admission assessments that clearly identified the care needs of residents. Care plans identified how resident’s assessed needs were to be met by identifying what actions and support needs were to be provided to care for residents properly. However the care plans had not been reviewed regularly. It is vital that care plans and risk assessments are reviewed on a regular basis St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 11 to record resident’s progress and formally identify changing care needs or increasing vulnerability from increased risks to resident’s health and welfare. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. Risk assessments were in place for whether a resident was at risk of falling. 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. However, as with the care plans, regular reviews of the risk assessments had been irregular. The care plans of the other two residents were not detailed enough. The care plan of one resident, who was actually in hospital on the day of inspection, showed that although he had been in the home for ten days there had been no risk assessments done for his diet and fluid intake, moving and handling, pressure sore or falls. Neither had he been weighed on admission. The care plan of another resident showed that he had several pressure sores and whilst he was being cared for properly and the staff had sought the advice of a nurse who specialises in the care and prevention of pressure sores, his care plan and risk assessments had not been reviewed and updated. Only one care plan was looked at on the nursing unit. This was detailed and up to date. The resident looked comfortable and well cared for. She was receiving the care prescribed in her care plan. All residents are registered with a local GP and it was evident that all were enabled to access opticians, chiropodists, district nurses and other specialist services that individual resident’s require (such as community psychiatric nurses and psychiatrists). Equipment necessary for the prevention and treatment of pressure sores was readily available within the home. A visiting GP told one of the Inspectors that he was satisfied with the care provided to his patient. The management of residents’ medicines on the Dementia Unit were inspected on this occasion. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 12 The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. The medicines were kept securely stored in a locked room and the medicine trolley was secured to the wall when not in use. The qualified nurses on the Dementia Unit are responsible for all aspects of looking after resident’s medicines that are under their care. The three residents’ medicine records inspected had been completed properly. Residents on the Dementia and Nursing Units were appropriately and cleanly dressed, well groomed and appeared to be supported by staff to maintain as much privacy and dignity as possible. However, two toilet doors on the Dementia Unit remained without overriding door locks. Management agreed to have these fitted by the following Friday, which they did. St Catherine`s Nursing Home DS0000005697.V334480.R01.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 & 15. Quality in this outcome area is poor. The residents on the Dementia Unit are not receiving a varied, nutritious and well-balanced diet. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The residents’ routines of daily living and their social interests were recorded in their care plans. An activities co-ordinator is employed to provide activities for each of the units. An activity chart is displayed within the reception area. Activities such as sing-a-longs, darts, dominoes, parties and games are provided between the hours of 2pm and 4pm each afternoon. Records are made for each individual to show what they have been actively involved in. On the day of inspection the residents on the Dementia Unit were having a game of dominoes. The inspectors did not dine with the residents but watched breakfast and lunch being served on the Dementia Unit. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 14 For breakfast the residents were having porridge, tomatoes, fried eggs, toast and tea. The residents seemed to be enjoying their breakfast. The Inspectors were told that the residents have a lighter meal at lunchtime and the main meal in the evening, except on Fridays when they have a fish and chip meal at lunchtime. As the inspection was undertaken on a Friday the Inspectors saw that it was a fish and chip meal for lunch. The menu for the day was fish, chips and peas or, for the residents who needed a soft diet, cottage pie, peas and carrots. Bread and butter were not provided. The Inspectors asked why the residents were not given bread and butter and were told that it is not sent up at meal times. Management agreed to make sure that bread and butter was sent up routinely. For the sweet it was rice pudding. On asking the cooks about what they prepare for people with diabetes, they said that all the residents have the same because they do not put sugar in the rice pudding. They also said that they do the same for whenever they are serving custard. The cooks and management were told that this is not acceptable, as the residents on the unit need their sugar and calories. Management agreed to discuss the issue with the cooks and change this practice. Management have sent CSCI an action plan stating that there will be a list showing which residents have diabetes and require a low sugar diet. All other residents will receive a separate choice of pudding. The menu for the evening meal that night was soup and sandwiches or scrambled eggs and tomatoes. The pudding was jam and cream cakes and the cooks told the Inspector that this could be “mashed up” for the people who require a soft diet. If this was still too solid then yoghurts were available. Staff told the inspector that sometimes some residents who have a soft or liquidised diet are still only getting soup for their meal. This was because there was not always a soft diet alternative. The Inspector was also told that if a resident was having a light meal and not soup and sandwiches then they were not always given soup, even they it was clear to the staff that they wanted it or would benefit from having it, as not enough was sent up from the kitchen. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 15 A discussion with the cooks showed that they do not make soup for everybody and they felt that the staff were giving the soup and sometimes soft diets to the residents that it wasn’t meant for. This indicates that the residents have little choice in what they prefer to eat and that choices are made by the kitchen staff and not by the residents. An action plan sent in by management showed that they were making sure that the cooks record the soft food choices that are prepared each meal-time and that food charts would be completed after every meal for those residents who require a soft diet. A further discussion with the kitchen staff showed that the home does not have a supply of fresh vegetables. They told the Inspector that they do have fresh fruit but apart from some bananas being in stock there had been no fresh fruit delivered for the last two weeks. The inspector asked how they ensured that, when they had fresh fruit, the residents on the Dementia Unit were able to get any. They were not able to say. Management agreed to make sure that it was served up into manageable pieces as snacks throughout the day and also served up at every meal. Management also agreed to order fresh vegetables. A discussion with a care assistant showed that the care staff decide what drinks are served from the trolley. She told the Inspector that there was always tea and normally cold drinks, especially in warm weather but that coffee and milky drinks are not routinely served. Management agreed to ensure that there will always be a choice of tea, coffee and fruit juice and that milky drinks will always be served in the morning and evening. The Inspector asked if the cooks had received any training in relation the special diets. They said that they had not and they referred to the book that was available in the kitchen. Management have sent in an action plan showing how they are going to ensure that the cooks receive training. The meals for the nursing unit are sent up in a heated trolley and food is served directly from it. This is an improvement from the last inspection when food was being sent up already plated. This allows a choice of food and second helpings if required. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 16 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. People 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. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A complaints procedure was in place and was displayed in the reception area. It was easy to understand and gave an assurance that complaints would be responded to within 28 days. Since the last inspection in January 2007, four complaints have been made to the CSCI. These complaints were mainly about care and staffing issues on the Dementia Unit. The Inspector looked at some of the issues during the inspection and found that some parts of the complaints were substantiated but it is evident that the new manager is working hard to improve things. In answer to the Question on the Have Your Say document: Do you know how to make complaint about the care provided by the home? • I have voiced my opinions at various times and requested certain procedures to be put in place. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 17 A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with the care staff showed that they were very aware of the procedure to follow in the event of any allegation of abuse. Training records were inspected and showed that training in the protection of vulnerable adults had been undertaken and was an ongoing process. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is adequate. The residents live in a suitably adapted environment that is gradually being improved. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Only the environment on the Dementia Unit was looked at in detail on this inspection. 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. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 19 On the day of this unannounced inspection the unit was clean and the management of the smell of urine has improved since the last inspection, although some areas of the unit still require attention in respect of this. The corridors were clean, reasonably decorated and have benefited from recently fitted vinyl floor covering. Some corridor walls have been decorated with sporting items and pictures and the inspector was informed it is the intention to theme the other corridors similarly. This will certainly make these areas of the unit more homely and stimulating for residents. The lounges and dining area of the unit were clean, warm and adequately/appropriately furnished. There were enough toilets and bathrooms to meet the needs of the residents. The toilet and bathrooms were clean and appropriately fitted/adapted for disabled use. Two of the toilet doors remained without an overriding door lock. Management agreed to have these fitted by the following Friday, which they did. All resident’s bedrooms were inspected on this occasion. These were clean, warm and adequately furnished (although a number still require to be fitted with lockable spaces for the residents to store anything that is of value to them). The bedrooms were fitted with a nurse call system, were provided with clean and appropriate bed linen and some were highly personalised. A small number of bedrooms (these were identified to the manager on the day of inspection) smelt of urine. This problem needs to be assessed in relation to the continence needs of the residents who occupy these rooms and action taken to address the issue. The laundry was clean and looked organised. Adequate equipment was in place and protective clothing was available. Staff and resident hand washing facilities were in place in the residents’ bedrooms, bathrooms and toilets. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 20 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 adequate. The residents are being cared for by staff who are suitably trained and experienced. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Dementia Unit Examination of the duty rotas and a discussion with staff on the Dementia Unit showed that management were trying to provide two qualified nurses between the hours of 8am to 2pm and five care assistants and one qualified nurse and five carers from 2pm to 8pm. From the rota it was seen that this was planned but the agency nurse booked to work the morning shift did not turn up. During the night one qualified nurse and two carers staff the unit. The Inspectors were told that the recently appointed unit manager had left but management were in the process of employing a new manager for the unit. They had recently employed a full time mental health nurse for the unit who was working on the day of inspection. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 21 The staff spoken to felt that they just about managed to get through their work. The unit does use agency staff on a regular basis however the agency staff on duty on the inspection day had been working at the home for a long time. The agency care staff told the Inspector that that they had been coming here for a while and they felt that it was now getting better. Comments from the Have Your Say document were: • • I am well aware that so many EMI residents need a lot of care and supervision that isnt always possible due to shortage of staff. It is nigh impossible for so few staff to give 30 residents attention etc. I am well aware that there is no such utopian state and the EMI residents need a lot of attention that cant be given by so few staff In answer to the question on the Have Your say document: Does the care services meet the different needs of people? responses were: • • If there arent enough staff available how can all of their needs be met. It must be very confusing for residents when so many different agency staff are called in who are not familiar with the residents. I have always I found the staff very helpful and kind. They do a very good job for very poor wages. Nursing There was enough staff on duty to meet the needs of the 14 residents. The rota showed that the unit is staffed with one qualified nurse and two carers throughout the day and night. Staff spoken to said they felt that this was sufficient. The manager told the Inspectors that approximately 76 of care staff have achieved at least an NVQ 2 qualification in care. NVQ training in health and social care is an ongoing process within the home. Inspection of three staff personnel files revealed that two were satisfactory. They had been properly and safely employed. However, one file contained only one written reference (instead of two), no health declaration and there were some issues of concern in relation to the checking out of this persons’ criminal record disclosure (CRB). Management were told to take urgent action to make sure that it was safe to employ this person. They informed the CSCI that they had taken the urgent action required and confirmed in writing that the issue had been dealt with. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 22 Inspection of personnel files showed that the staff received induction training within six weeks of appointment to their post and further training within the first six months of appointment. Also a wide range of appropriate and ongoing training in moving and handling, protection of vulnerable adults, basic food hygiene, fire safety and other relevant topics are provided to staff at the home. Training provided to individual staff is recorded in detail and reviewed at frequent intervals. Staff spoken to felt their training needs were being addressed and many felt this made them more competent and felt more valued in their work. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 23 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 & 38 Quality in this outcome area is good. Practices within the home safeguard the welfare of the residents, staff and visitors. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home has very recently appointed a new manager who is in the process of being registered with the CSCI. She is a Registered General Nurse and a Registered Health Visitor. She has years of experience in care of the elderly, both in the NHS and the private sector. She has achieved the Registered Manager’s Award and keeps herself updated both with clinical and management subjects. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 24 In answer to the question on the Have Your Say document: How do you think the care home can improve? a response was: • By employing a good caring manager. Since my relative has been in the home there have been four. The Inspectors were not able to check out Standard 33 in relation to quality assurance or Standard 35 in relation to residents’ finances. These were, however, met on the inspection in June 2006. The home had a detailed Health and Safety Policy. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. The Inspector was informed that the company provide centralised fire training 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. St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 25 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 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 x x 2 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x 3 St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(2)(b) Timescale for action Staff must continually look at the 30/07/07 changing needs of the residents and review the care plans at least on a monthly basis. Staff must make sure that any 30/07/07 risk to the health and safety of the residents is identified and action to reduce or stop any identified hazard is then taken. Therefore, risk assessments for nutrition, falls, moving and handling pressure sores must be in place. Adequate food and drink must be 15/06/07 provided for all residents and residents must be given a choice in relation to the content and amount of food provided. Special dietary needs must be catered for. Action must be taken to 30/07/07 eradicate the smell of urine in the bedrooms on the Dementia Unit. Management must ensure that 11/06/07 all staff are safely recruited. The cooks must receive training 30/07/07 in relation to nutrition and special diets. DS0000005697.V334480.R01.S.doc Version 5.2 Page 27 Requirement 2 OP8 13(4)(c) 3 OP15 16(2)(i) 4 OP26 23(2)(d) 5 6 OP29 OP30 19(1)(a) 18(1) (c)(i) St Catherine`s Nursing Home RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 Good Practice Recommendations There should be evidence to show what food has been provided for the residents who require a soft or pureed diet. A lockable space should be provided in all bedrooms. OP24 St Catherine`s Nursing Home DS0000005697.V334480.R01.S.doc Version 5.2 Page 28 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.V334480.R01.S.doc Version 5.2 Page 29 - 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!