Inspection on 01/06/06 for St Catherine`s Residential Home

This inspection was carried out on 1st June 2006.

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.

Other inspections for this house

St Catherine`s Residential Home 28/10/08

St Catherine`s Residential Home 11/07/07

St Catherine`s Residential Home 02/02/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St Catherine`s Residential Home 326/328 Boldmere Road Boldmere Sutton Coldfield West Midlands B73 5EU Lead Inspector Brenda O`Neill Unannounced Inspection 1st June 2006 09:00 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 Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Catherine`s Residential Home Address 326/328 Boldmere Road Boldmere Sutton Coldfield West Midlands B73 5EU 0121 377 8178 F/P 0121 377 8178 kathline@btconnect.com 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) Ms Pearl Goss Ms Pearl Goss Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Provide assisted bathing/showering facilities in ground and first floors within eighteen months of registration. Any of the four rooms used for double occupancy must be in excess of 16sqm so each occupant has adequate space for furniture and belongings. Fit bedroom door locks (which are suited) within twelve months of registration. Provide all items of furniture as detailed within the National Minimum Standards within twelve months of registration. 2nd February 2006 Date of last inspection Brief Description of the Service: St Catherine’s is a large detached Victorian property that is situated on the Boldmere Road, Sutton Coldfield. It is within easy reach of shops and local facilities. The home is registered to provide accommodation to 22 residents for reasons of old age. Accommodation is provided over three floors in a mixture of single and double rooms, some of which have en-suite facilities, and a shaft lift gives access to the first floor and second floors. Communal accommodation consists of a lounge, dining room and a conservatory that looks out onto an enclosed wellmaintained garden. The home has one assisted bathroom on the top floor of the home, a bathroom and shower room on the first floor and two bathrooms on the ground floor, only the toilet facilities are used in these rooms by the residents due to accessibility difficulties. The home also has office space, staff room, laundry and kitchen which are all located on the ground floor. There is adequate parking to the front of the property with ramped access to side entrances. The fees at the home ranged from £361 to £420 per week. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by two inspectors over one day in June 2006. During the inspection a tour of the premises was carried out, three resident and two staff files were sampled as well as other care and health and safety documentation. The inspectors spoke with the manager, one member of staff and seven of the sixteen residents. Prior to the inspection the inspector received a completed pre inspection questionnaire that included information about the home, residents and staffing and several completed relative and resident comment cards. What the service does well: The home had a friendly and welcoming atmosphere and was well managed with a stable staff team which was good for the continuity of care of the residents. There were good relationships evident between the staff and the residents and the comments received both prior to and during the inspection from residents and relatives were positive. These included: ‘The staff work very hard and are always pleasant.’ ‘I couldn’t be happier here.’ ‘Staff work really hard for every occasion.’ ‘Families have lovely newsletters every month and we always know what is going on.’ ‘There is always someone within calling distance and there is an alarm by my bed.’ ‘Very attentive.’ Prospective residents were able to visit the home prior to admission to assess the facilities and were issued with a statement of terms and conditions of residence at the point of admission. There was evidence that the health care needs of the residents were being identified and followed up by staff. The system in place for administering medication was well managed and safe. There were no apparent rigid rules or routines in the home and there were activities available for those residents that wished to take part that were facilitated by both staff and outside agencies. There were no restrictions on visitors to the home within reasonable hours and visitors were made very welcome. The home was very well maintained and comfortable. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: All residents needed to have comprehensive assessments prior to admission to the home to ensure their needs were known and could be met by the staff. The manager needed to ensure that all the residents had comprehensive care plans and risk assessments detailing how individual needs were to be met and any risks minimised. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 7 The manual handling risk assessments needed to be further developed to include the actions to be taken by staff in the event of a fall. Recruitment procedures needed to be applied consistently ensuring all staff had the appropriate checks in place prior to commencing their employment. The manager needed to ensure that all staff had up to date training in safe working practices and make arrangements for them to have training on the ageing process and associated illnesses. Improvements needed to be made to the assisted bathing facilities in the home to ensure they were appropriate for the residents. The emergency call system needed to be accessible from all bathing, toilet and shower facilities. To enhance the infection control systems in place the clinical waste needed to be stored appropriately whilst awaiting collection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There were good systems in place for assessing the needs of prospective residents but these needed to be applied consistently to ensure the staff knew and could meet the needs of individuals admitted to the home. Prospective residents were able to visit the home to assess the facilities prior to admission and were issued with a statement of terms and condition of residence at the point of admission. EVIDENCE: The files of two residents recently admitted to the home were sampled. One of these included a thorough pre admission assessment that had been carried out by the home prior to admission and also an assessment that had been undertaken on the day of admission that established the various likes, dislikes and preferences of the individual, for example, preferred rising and retiring times, whether they liked a bath or a shower, preferred drinks and foods and so on. These assessments then formed the basis of the care plan. The other St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 10 file did not include this documentation and only basic information was available at the pre admission stage. There was evidence that a social worker had been involved in the admission of one of the residents. There was evidence that residents were able to visit the home prior to admission and that a statement of terms and conditions of residence was issued at the point of admission. Residents had all been issued with an updated statement of purpose and service user guide as recommended at the previous inspection. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There were good systems in place for care planning and minimising the identified risks for the residents but these needed to be applied consistently for all residents. The health care needs of the residents were being met and the medication system was well managed and safe. EVIDENCE: Three care files were sampled. Two of these included very comprehensive care plans that had been drawn up in consultation with the residents. The care plans covered all the required areas including, personal care, medical needs, dietary requirements and social needs. There was good detail of what the residents were able to do for themselves and what assistance they needed. Individual likes, dislikes and preferences were also included. The other file did not include a care plan and only had basic details of the residents needs. All the files sampled included booklets entitled ‘assessment for good care planning’ which included numerous risk assessments including, nutritional and tissue viability assessments, mental health and falls assessments. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 12 There were also separate personal risk assessments on the files for any additional risks or where a risk had been identified on any of the assessments. These risk assessments detailed how staff were to minimise any identified risks. It was noted that one of the residents had a sensory impairment and there was no risk assessment in place for this. The manager needed to ensure that there were risk assessments in place for any identified risks. Since the last inspection manual handling risk assessments had been undertaken for all residents however these did not include the actions to be taken by staff in the event of a fall if the person was not injured. The manager had introduced a comprehensive falls procedure for staff to follow however the handling techniques to be used needed to be individualised for each resident. The daily records sampled were generally satisfactory and gave an overview of the residents’ well being and of some of the personal care being given. Visits from health care professionals were recorded separately and easy to track and cross reference to daily records. The daily records evidenced that staff were identifying any health care needs and these were being followed up promptly and monitored. Residents spoken with confirmed they could see the doctor if they wished and that they had visits from the chiropodist, optician, district nurses and so on when necessary. The medication system continued to be well managed. All medication was acknowledged when it was received into the home and administered or codes used when not administered. All the medication audited during the course of the inspection was correct. One requirement was made about having protocols in place for the administration of PRN (as and when necessary) medication. It was also recommended that the manager carried out regular staff drug audits to ensure the competency of staff as one method of overseeing the system on an ongoing basis. The residents spoken with did not raise any issues about their rights to privacy not being upheld and residents were observed to spend times in their rooms without being disturbed if they wished. Staff were seen to knock doors before entering, medical consultations took place in the privacy of residents’ bedrooms and they could meet with their visitors in their bedrooms or one of the quieter areas of the home. There was a telephone for the use of the residents which did allow for some privacy when making or receiving calls as it was in an area that was not in constant use however privacy would be further enhanced if it could be relocated to an area where residents would not be overheard. The manager did confirm with the inspector that ways of achieving this were being explored. All bedrooms had a lockable facility and the day after the inspection the home was due to have locks fitted to all the bedroom doors to enable residents to be able to lock their doors if they wished. Residents were addressed appropriately by staff and their preferred names were detailed on the care files. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home and there were activities available if the residents wished to take part. There were no restrictions on visitors to the home within reasonable daytime hours. The residents spoken with were happy with the catering arrangements at the home. EVIDENCE: Routines in the home were kept to a minimum and residents were able to choose how they spent their time. Residents were seen to wander freely around the home, take part in a church service, have manicures, meet with their visitors or spend time quietly in their rooms. There were activities on offer if the residents wished to take part including, extend (exercise) and reminiscence which were facilitated by outside agencies, quizzes, sing a longs, cards, dominoes, skittles and so on that were facilitated by staff. There were also visiting entertainers to the home once a month. Although there were individual activity sheets for the residents these were not always adequately completed and did not include everything that the residents were participating in. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 14 There were no restrictions on visitors to the home within reasonable daytime hours and visitors were seen to come and go throughout the course of the inspection and there were evident friendly relation ships with staff. Some of the residents continued to go out independently. One resident talked about going out on a daily basis and using the train and that he had just applied for the ring and ride service. Another resident was going out to a club to play scrabble on the day of the inspection and another had gone out shopping. The manager was in the process of registering all the residents at the home with the local ring and ride service to enable them to go out more often. There was evidence in the residents care plans of where they were able to make choices and that these were to be offered. Residents stated they were able to go to bed and get up when they chose and spend their time as they chose. Residents were encouraged to personalise their rooms to their choosing and evidence of this was seen during the tour of the home. All the residents spoken with during the course of the inspection were satisfied with the catering arrangements. One or two issues were raised on the comment cards received prior to the inspection and these were discussed with the manager who knew about them and was trying to address. Residents’ comments included: ‘ The meals are wonderful and varied’ ‘They are rather bland and repetitive’ ‘I do not have a large appetite but always have enough to eat.’ One relative commented: ‘My mother eats really well and food is lovely. Most Sundays and ‘special days’ I stay for lunch. The inspectors joined the residents for lunch and the meal was well cooked and presented. Staff were available to offer assistance where necessary, the meal was unhurried and appeared to be enjoyed by all the residents. Diabetic diets were being catered for. Food records were being kept and although there were no choices on the menu it was evident from the records that when a resident did not like what was on the menu there were alternatives available. It was recommended that menu cards were put on the dining room tables so that residents knew well in advance what was for lunch and tea so that they could tell the chef if they wanted something different. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. There was an appropriate complaints procedure in the home and all residents had been issued with a copy. There were systems in place to ensure the protection of the residents. EVIDENCE: The home had not received any complaints and none had been lodged with the CSCI. There was an appropriate complaints procedure on site that had been amended as required at the last inspection and all residents had been issued with a copy of this. Residents spoken with stated they would raise any issues they had with the manager and appeared confident that she would address them. There were policies and procedures on site in relation to adult protection and whistle blowing and the manager had obtained a copy of the multi agency guidelines for adult protection. The adult protection policy needed a minor amendment to ensure it complied with the multi agency guidelines and this was discussed with the manager. Some staff had received training in adult protection and further training was planned for the day of the inspection however the trainer cancelled this as she was unwell and was to be rescheduled. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home offered residents clean, comfortable, spacious and well maintained accommodation. Some issues needed to be addressed to ensure there were adequate, accessible bathing facilities available for the residents. EVIDENCE: There had been no changes to the layout of the home which was generally suitable for its stated purpose, well maintained, safe and comfortable. There was adequate communal space in the home comprising of a large lounge, dining room and a large conservatory. All were adequately decorated and furnishings and lighting were domestic in character. Since the last inspection the conservatory had had new flooring and furniture and a large aquarium had been installed and it was a very pleasant room. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 17 As at the last inspection there were some bedrooms that had en-suite facilities and there were a number of bathrooms throughout the home. There was however, only one assisted bathing facility, this was the medic bath on the second floor. On the first floor there was a shower but this was not accessible to the residents and only the toilet in this room was used. The two bathrooms on the ground floor were very small and not adapted and again only the toilets were used. These two bathrooms had been redecorated and had mirror tiles put up giving the impression of larger rooms and making them much more pleasant for the residents to use. The home needed to have at least one assisted bathing facility on each floor and one of the conditions of registration was in relation to this. The manager had had plans drawn up to address the issue on the ground floor. The aids and adaptations in the home included, shaft lift, grab rails and ramped entrance. There was an emergency call system throughout the home however the manager needed to ensure it was accessible from all bathing and toilet facilities. Bedrooms in the home varied in size and most exceeded the required space. None of the bedrooms were being used as doubles at the time of the inspection. It was noted that some of the bed bases were worn however these were being replaced in order of priority. The day after the inspection all bedroom doors were to be fitted with locks and all rooms had a lockable facility. Not all the rooms had all the furnishings required by the National Minimum Standards, for example, some rooms had only one chair this was also a condition of registration and the time scale for completion had not expired at the time of the inspection. The home was centrally heated and all radiators had been guarded. All rooms were naturally ventilated and window restrictors had been fitted where necessary. The manager had had the water system checked for the prevention of legionella since the last inspection. The home was found to be clean, generally hygienic and odour free. The manager needed to ensure that clinical waste bins in the home were foot operated and that all clinical waste awaiting collection was in bins with tight fitting lids. The kitchen and laundry were appropriately located and equipped. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. A stable staff team was maintaining adequate staffing levels. Recruitment procedures needed further improvement to ensure they protected the residents. The manager needed to ensure that staff had undertaken all the required training in safe working practices and some training on the ageing process. EVIDENCE: There had been little staff turnover at the home since the last inspection and some of the staff had worked there for a considerable amount of time which was very good for the continuity of care of the residents. All residents spoken with were very positive in their comments about their relationships with the staff. The rotas demonstrated that there were adequate numbers of staff on duty and that the manager’s hours were supernumerary. The home also employed a cook and domestic assistant. The recruitment files for two staff were sampled. One of these was complete and included all the required documentation, for example, completed application form, two written references and an enhanced CRB check. The other file included the majority of the documentation but no CRB or POVA first check had been obtained. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 19 It was also recommended that the manager kept records of the interviews she undertook with prospective employees and included any discussions she had about gaps in previous employment. There was evidence on the files sampled that new staff were undertaking induction training in line with the specifications laid down by Skills for Care. These records were well detailed and covered all the required areas. The training matrix for the home evidenced that some staff had undertaken some of their regulatory training, for example, fire, food hygiene and manual handling however the manager needed to ensure that all staff completed all their training in safe working practices. Staff had also undertaken training in topics such as skin care, medication and a short session on dementia. The manager also needed to ensure that staff undertook some training in the ageing process and associated illnesses as appropriate, for example, diabetes. Over 50 of the staff employed at the home were qualified to NVQ level 2 or above. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The manager of the home ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was well managed. Systems were being put in place to continuously monitor the service on offer with a view to continuous improvement. EVIDENCE: The owner of the home was also the manager and had taken over the home in August 2005 and numerous improvements had been made since she had taken over. This was evidence by the reduction in the number of requirements made following this inspection in comparison to the first inspection in September 2005 (over 40 to 14). She had many years experience of caring for elderly people and the running of a care home. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 21 She had a relevant management qualification but had chosen to also undertake the Registered Manager’s Award and will then undertake the required care modules to give her all the required qualifications. Residents were very positive about their relationships with her and her partner who also had a lot of input into the home. It also appeared that relationships with staff were good and they were very positive about the changes that had taken place in the home. The manager was in the process of implementing a system for monitoring the quality of the service offered with a view to continuous improvement. Several audits were taking place including such things as, cleanliness and safety of rooms, checks on water temperatures, fire doors and emergency call bells. A variety of questionnaires had been produced for staff, residents, relatives and visiting professionals. The staff questionnaires had been completed and returned and the manager was to analyse these. The manager was also producing a monthly newsletter for relatives which kept everyone up to date with what was going on in the home including, staffing, forthcoming activities, fund raising and plans for the improvement of the environment. The manager did not handle any finances on behalf of the residents and was satisfied that the residents had access to what they needed. One resident continued to manage his own financial affairs and others managed small amounts of personal cash. There was evidence that staff supervision was taking place and the programme for this indicated that the required levels would be met. Health and safety of the staff and residents were well managed. There was evidence on site that all the required checks on the fire system were taking place and that staff had had a fire drill. All the equipment being used was being serviced regularly and the water system had been tested for the prevention of legionella. There were risk assessments on site for the premises, fire and food hygiene however there were no risk assessments in place for staff, for example, for lone working, escort duties and so on. It was also noted that the risk assessments in place were very mixed up and overlapped considerably. It was recommended that these be reorganised. Staff were signing to say they had read the risk assessments. Accident and incident recording had improved since the last inspection as had the frequency of the notifications to CSCI. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 1 2 X 2 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 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 OP3 Regulation 14(1) Requirement The manager must ensure that prior to admission to the home a comprehensive assessment of the individuals needs is undertaken and records maintained. Previous time scales of 01/12/05 and 01/03/06 partially met. All residents must have a care plan in place that details all their needs and how these are to be met by staff. Manual handling risk assessments must detail the actions to be taken by staff in the event of a fall if the resident is not injured. All residents must have personal risk assessments in place for all identified risks. Previous time scale of 01/04/06 partially met. There must be protocols in place for the administration of PRN medication. Staff must ensure they record how residents are spending their times to evidence their social needs are being met. DS0000064065.V294448.R01.S.doc Timescale for action 01/07/06 2. OP7 15(1) 14/07/06 3. OP7 13(5) 14/07/06 4. OP7 13(4)(c) 14/07/06 5. 6. OP9 OP12 13(2) 12(1)(a) 01/07/06 14/07/06 St Catherine`s Residential Home Version 5.1 Page 24 7. OP18 13(6) 8. OP21 23(2)(j,n) 9. 10. OP22 OP24 23(2)(n) 16(2)(c) 11. OP26 13(3) The adult protection procedure must be amended to ensure it complies with the multi agency guidelines. Assisted bathing/showering facilities must be provided on the ground and first floors. Previous time scale had not expired. The emergency call system must be accessible from all bathing, toilet and showering facilities. All bedrooms must be equipped with all the furnishings as detailed in the National Minimum Standards. Previous time scale given had not expired. Clinical waste bins in the home must be foot operated. Clinical waste awaiting collection must be in bins with tight fitting lids. The manager must ensure that as a minimum a POVA first check is obtained for all staff prior to their commencing their employment. Previous time scale of 01/03/06 not met. The manager must ensure that all staff have all the required regulatory training. 14/07/06 12/02/07 01/08/06 12/08/06 14/07/06 12. OP29 19(1) 01/07/06 13. OP30 18(1)(a) 01/09/06 14. OP31 9(2)(b)(i) Arrangements must be made for staff to undertake training on the ageing process and associated illnesses. The registered manager must be 01/12/06 qualified to NVQ level 4 in care and management. The manager must develop risk assessments for staff. 01/08/06 15. OP38 H&S at Work Act St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 25 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. 4. Refer to Standard OP9 OP10 OP15 OP29 Good Practice Recommendations It is recommended that the manager undertakes staff drug audits before and after a medicine round to confirm staff competence in medicine management. It is recommended that the telephone for the use of the residents is relocated to an area where they cannot be overheard. It is recommended that the daily menus are put on the dining room tables so that the residents know well in advance what their meals are for the day. It is recommended that interview records are kept for prospective employees that include details of any discussions in relation to gaps in previous employment. St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Catherine`s Residential Home DS0000064065.V294448.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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