Inspection on 11/07/07 for St Catherine`s Residential Home

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 01/06/06

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 Mrs Amanda Hennessy Key Unannounced Inspection 11th July 2007 09:45 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.V337097.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 Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 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.V337097.R01.S.doc Version 5.2 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. 1st June 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 range between £332 to £488 per week and are dependent on the needs of the residents and the room that they occupy. Hairdressing, toiletries, newspapers, Non National Health Service chiropody and physiotherapy are not included in the fee. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection undertaken without any prior notice by one Inspector. The inspection was carried out between 9.45 and 17.45. The inspection included a tour of the building, talking to service users, relatives, staff and the Manager, a review of records including information forwarded by the Manager before the inspection and survey comment cards that were completed by service users and their relatives. Care records were reviewed as part of the “case tracking” of three service users. The home has been both owned and managed by Pearl Goss since August 2005. Fourteen of the previous fifteen requirements have been addressed, or removed as they no longer applicable; one new requirement was made as a result of this inspection. What the service does well: St Catherine’s residential home is clean, friendly, welcoming, well maintained and comfortable. The home has an experienced manager who provides effective and competent leadership for her staff. There is a stable staff team who provide continuity of care for the homes residents and there is a high percentage qualified care staff. All prospective residents have a comprehensive assessment of their needs and are able to visit the home and have a meal there prior to their agreement to come to live at the home. Residents have appropriate access to health care and the health care needs of the residents are identified and followed up by staff. The home has appropriate and safe administration and storage of medicine. There are no apparent rigid rules or routines in the home. Residents enjoy the activities and entertainment sessions that take place and appreciate the newsletter that informs them of what forthcoming activities and events at the home. There are no restrictions on visitors to the home within reasonable hours and visitors say that they are always made welcome. Residents say that the homes staff are very good, comments received included: ‘I like it here because the staff are very good.’ ‘The staff are so kind and patient.’ St Catherine`s Residential Home DS0000064065.V337097.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 Residential Home DS0000064065.V337097.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 Residential Home DS0000064065.V337097.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): Standards 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home have an assessment of their needs and all required information about the home, giving assurance that the home will be able to meet their needs. EVIDENCE: People who wish to live in the home have an assessment of their needs prior to coming to live at the home. The Manager confirms in writing that the home can meet their needs, the date that they can come into the home and the room that they will have. Further information is taken when the residents come to live at the home that identifies their likes, dislikes and their preferences, for example, preferred rising and retiring times, whether they liked a bath or a shower and how often they prefer a bath or shower, preferred drinks and foods and so on. These assessments then formed the basis of their plan of care. Prospective residents are invited to visit the home and can join the existing residents for lunch if they wish to. The manager said she gives all new St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 9 residents a copy of the homes service user guide. All residents are also given terms and conditions of residency giving them all required information about the home. St Catherine`s Residential Home DS0000064065.V337097.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): Standards 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. There are good systems in place for care planning and minimising the identified risks for the residents but they need to be further developed to ensure care records reflect care that is given to residents. The health care needs of the residents are being met and the medication system was well managed and safe. EVIDENCE: People who live at the home have a plan of care that identifies their needs and gives staff instructions how to meet their needs. Care plans seen covered all required areas including, personal care, medical needs, dietary requirements and social needs. It was nice to see a record of what residents are able to do for themselves and what assistance they require. Individual likes, dislikes and preferences were also included. It was pleasing to see that the majority of residents have a comprehensive review which is undertaken monthly which involves the resident, key worker and Home Manager and identifies how the resident has been within the previous month, whether they have had any falls, changes in medication and visits by a health professionals and hospital visits. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 11 One resident care records seen however, did not identify any review for four months after their admission. It was also noted that frequently care plans were not dated making it difficult to identify which was the most up to date plan of care. Two residents health needs had changed, one resident had been unwell and had lost 8 kilograms and another had greater difficulty walking and had a small pressure sore. It was evident that staff were following instructions such as a need for a pressure cushion given to them by Health professionals but there was no record of these instructions in their plan of care. All residents care records seen, included booklets entitled ‘assessment for good care planning’ which included numerous risk assessments including, nutritional and tissue viability assessments, mental health and falls assessments. There are separate risk assessments that identify residents moving and handling needs. All risk assessments are reviewed six monthly but should be reviewed and when appropriate updated monthly. Any changes to their risk assessment, such as the resident who had the pressure sore must inform a change of their care plan. There are also separate personal risk assessments on the files for any additional risks when required. Records of people life within the home (daily records) give an overview of the residents’ day including their well being, personal care given and activities they take part in. Visits from health care professionals are 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. 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 home has good systems in place to administer and store of medicines. There is a record of all medicines that are received into the home and administered or codes identified when medicines are not administered and the reason why. Staff do not always record the administration of creams and lotions as required to give assurance that the creams and lotions have been applied. There is a record of the drugs fridge temperature to ensure that medicines are stored within safe temperatures. It is recommended that the fridge is either locked or medicines are kept within a locked box within the fridge to further safeguard residents’ medicines. A requirement made at the previous inspection to have protocols in place for the administration of PRN (as and when necessary) has been addressed. 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. It was also lovely to see staff giving a resident who had been unwell and had been unable to walk around unaided time to get up and get into his chair supporting him to maintain his independence. Medical consultations take place in the privacy of residents’ bedrooms. All bedrooms had are lockable if St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 12 residents wish to. Staff address residents appropriately, with their preferred names are detailed within care files. St Catherine`s Residential Home DS0000064065.V337097.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are no rigid rules or routines in the home and residents can take part in a range of activities of their choice. There are no restrictions on visitors to the home within reasonable daytime hours. Residents are happy with the catering arrangements at the home. EVIDENCE: Routines in the home are kept to a minimum and residents are able to choose how they spend their time. One resident spoken to said: “ There is a lot of freedom here in everything, there are no restrictions.” The “extend” sessions that include gentle exercise and reminiscence is particularly popular with residents. The home also has a monthly church service and a monthly visit from a range of professional entertainers including singers, magicians, Old Time Music Hall performance and a planned “Tribute to the Black and White Minstrel show”. Staff also do quizzes; sing a longs, cards, dominoes, skittles and manicures with the residents. Residents and families also said that they appreciated the homes monthly newsletter. Residents spoken to said they enjoy the activities that take place. Comments received were summed up by a relative who said; St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 14 “I feel the owners do a great job by having regular entertainment for the residents”. There are 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 have a good relationship with staff. Visitors spoken to said: “ We can come at any time and staff always make us welcome”. It was pleasing to hear that the home has some residents who are able to go out independently to enjoy a full and active life. Residents stated they are able to go to bed and get up when they chose and spend their time as they chose. Residents are 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 inspection were satisfied with the catering arrangements. Residents said: ‘ The meals are very good’ Lunch was observed, with staff giving residents assistance when necessary, the meal was unhurried and appeared to be enjoyed by all the residents. It was also nice to see tables appropriately laid and residents helped to get up to the dining table. One resident spoken to said he liked living at the home as she was still able to have a can of beer and a “ Baileys” before he went to bed. 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 alternatives were available. St Catherine`s Residential Home DS0000064065.V337097.R01.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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure but it should be more widely available in appropriate formats for residents to give assurance that people are fully informed of the complaints process. Staff undertake appropriate actions to safeguard residents, although a minor amendment of the adult protection policy would give greater assurance that residents are more fully safeguarded. EVIDENCE: Residents spoken to said they would not hesitate to raise any concerns (if they had any) with the Manager. Residents are given a copy of the complaints procedure within their “Service User Guide” when they come to live at the home. The complaints procedure is not displayed in the home and it is currently not available in any other format such as large print, which the Manager was recommended to do. The Commission for Social Care Inspection has received one complaint about the home. The Complainant expressed concern that the home did not a have hoist for a resident who was unable to stand following a recent decline in his health and a fall. The Manager had undertaken a detailed investigation of these concerns and said that she had discussed her finding with the complainant. Unfortunately she had not concluded her findings in writing and forwarded a copy to the complainant as would be expected. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 16 The home has policies and procedures for safeguarding people who live at the home. The manager has obtained a copy of the local authority multi disciplinary policy for safeguarding people, but there is a need for the homes policy to reflect this policy. The home has had one adult protection investigation, which was highlighted by the Manager and was appropriately managed. Staff spoken to were clear of actions that they would undertake if allegations of abuse were made. Staff receive training in adult protection. One resident’s care records had been signed by his relatives. The Inspector discussed the new mental capacity Act and advised the manager to review information available on the Department of Health web site to ascertain how it would affect the home and actions that need to take place under the new act. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 17 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): Standards19, 20, 21, 22, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, warm and well maintained making it a pleasant and homely place for residents to live. EVIDENCE: The home is warm, homely and pleasant. There is a large lounge, dining room and a large conservatory, with residents and visitors spoken to saying how much they enjoyed sitting in the conservatory and enjoyed watching the fish in there. Several residents said how much they enjoy the garden, which is planted with a variety of shrubs, flowers, trees and grass. There are steps to the second level of the garden but all residents are able to access the lawned area outside the conservatory and sit on the garden furniture available there. All areas of the home are appropriately decorated and furnishings and lighting were domestic in character. The proprietor has been undertaking a St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 18 programme of redecoration and refurbishment since she has owned the home. Several bedrooms, the lounge and dining room have been decorated and a new assisted bath and shower facilities have been installed which again residents like. Residents commented on the many improvements made to the home since the current proprietor has owned it. The aids and adaptations in the home include, shaft lift, grab rails and ramped entrance. The home has an emergency call system throughout and a requirement that emergency call buzzers are accessible in toilets and bathrooms has been addressed. The home has bedrooms with and without ensuite facilities. The majority of bedrooms are spacious and exceed the required size. The home has both single and double bedrooms but no bedrooms are currently used as double rooms. All bedroom doors have locks and there is also a lockable facility within residents’ rooms for them to keep treasured items if they wish to. The home is centrally heated and all radiators are guarded to protect resident. All rooms are naturally ventilated and window restrictors had been fitted where necessary. There are regular checks on the water system with checks also undertaken for the prevention of infection by an outside contractor, which again gives residents assurance of the safety of the hot water supply. The home was found to be clean, generally hygienic and odour free. Requirements made at the previous inspection to have foot operated clinical waste bins and ensure that all clinical waste awaiting collection was in bins with tight fitting lids has been met. The kitchen and laundry were appropriately located and equipped. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 19 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): Standards 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. There are sufficient staff to meet residents needs. Recruitment and selection procedures are robust and safeguard the service users. Staff training opportunities are good. EVIDENCE: There are sufficient staff to meet residents needs. The home also has a cook who is employed seven days a weeks. There is currently a vacancy for a domestic and currently the existing domestic works every other day with staff undertaking light domestic duties when there no domestic assistant is available. There has consistently been very little staff turnover at the home, which provides good continuity of care for residents. All residents spoken with were very positive in their comments about their relationships with the staff with statements such as: “ I like living here because the staff are so good” “The staff are so kind and patient with my relative” The home currently has a high percentage of qualified care staff with 9 of its 11 care staff (82 ) with a minimum of National Vocational level 2 qualification St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 20 (NVQ) or equivalent. The manager also said that several care staff also have their NVQ 3. Recruitment and selection procedures at the home are robust and protect the service users with all required checks in place before the new employee commences work. New staff receive induction training and it’s as pleasing to see all staff have regular staff supervision sessions. Staff have monthly training sessions with recent training including fire safety, moving and handling, protection of vulnerable adults and food hygiene and dementia. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home provides effective leadership to ensure the smooth running of the home. Systems are in place to continuously monitor the service on offer with a view to continuous improvement and ensure that people who live at the home are listened to. Residents’ health and safety is safeguarded at the home. EVIDENCE: The manager of the home is also its owner and has owned the home since August 2005. She has made and continues to make improvements to the home to ensure that the home is comfortable and has the aids and adaptations to meet people’s needs. She had many years experience of caring for elderly people and the running of a care home. She had a relevant management St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 22 qualification and is undertaking her Registered Manager’s Award and will then undertake the required care modules to give her all the required qualifications. Residents are very positive about their relationships with her and her partner who also had a lot of input into the home. A comment from one relative summarised the views of residents and relatives: “ We have seen a steady but very positive improvement in the standard of the accommodation and care provided since Mrs Goss became the owner. There is every indication that this will continue in the future.” The manager is keen to improve her home and has a programme of monitoring the quality of care and continuous improvement within the home. Several audits take place including; cleanliness and safety of rooms, water temperatures, fire doors, emergency call bells, care plans and medication. Surveys were sent out to staff, residents, relatives and visiting professionals and have been analysed and actions required identified. The manager produces a monthly newsletter for relatives which keeps 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 home does not handle any finances on behalf of the residents. One resident manages his own financial affairs and others managed small amounts of personal cash. Records seen shows that staff receive supervision at the required frequency. Health and safety of the staff and residents is well managed. Required checks on the fire system take place although there is a need to ensure that staff receive six monthly fire drills to ensure that they know what actions they should take in the event of a fire. All the equipment being used was being serviced regularly and the water system has been tested for the prevention of legionella infection. Required risk assessments for fire and food were also available. There are required and comprehensive reports of accident and incident and it was positive to see that the manager undertakes ongoing audits of residents accidents to ascertain patterns in the frequency, times and places that residents fall. St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 17 x 18 3 3 3 3 3 x x 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 3 x 2 St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 24 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(1) Requirement All residents must have a care plan in place that details all their needs and how these are to be met by staff. Timescale of the 14/07/06 not fully met. Adequate arrangements must be in place to ensure that staff who work at the home must have drills and practices at required intervals to ensure that they are aware of the procedure to be followed in the case of a fire, including the procedure for saving life. Timescale for action 31/07/07 2 OP38 23(4) 31/08/07 St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 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 OP14 OP16 OP16 Good Practice Recommendations The fridge where medicines are stored should be either locked or medicines within the fridge should be kept in a locked box within the fridge. The manager seeks information on the requirements of the Mental Capacity act. The complaints procedure should be displayed throughout home and is in a format that is accessible to people who live at the home. The complaints procedure is reviewed to ensure that systems are in place to ensure that the complaint is investigated within the required timescale, and that there is a written record of the feedback that is given to the complainant. The registered manager should be qualified to NVQ level 4 in care and management. 5 OP31 St Catherine`s Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Residential Home DS0000064065.V337097.R01.S.doc Version 5.2 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. 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