Inspection on 13/04/07 for St Catherines Care Home

This inspection was carried out on 13th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Catherines Care Home 01/09/05

St Catherines Care Home 29/04/05

St Catherines Care Home 07/01/05

St Catherines Care Home 16/07/04

St Catherines Care Home 15/09/03

St Catherines Care Home 04/11/02

St Catherines Care Home 26/02/02

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

CARE HOMES FOR OLDER PEOPLE St Catherines Care Home Barony Road Nantwich Cheshire CW5 5QZ Lead Inspector Anthony Cliffe Unannounced Inspection 13th April 2007 08:30 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 Catherines Care Home DS0000018740.V333483.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 Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherines Care Home Address Barony Road Nantwich Cheshire CW5 5QZ 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) 01270 610881 01270 610427 stcatherines@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care Carolyn Penfold Care Home 40 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (20), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Old age, not falling within any other category (20) St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: * Up to 20 service users in the category of OP (old age not falling within any other category). * Up to 20 service users in the category of DE(E) (Dementia over the age of 65) * Two named service users in the category of may be DE (dementia under 65) * One named service user in the category of MD(E) (mental disorder over the age of 65). 1st September 2005 Date of last inspection Brief Description of the Service: St. Catherines care home is a single storey building situated on the outskirts of Nantwich. The home provides nursing care for 20 older people diagnosed with dementia and 20 older people whose needs are due to physical frailty. The home is operated by Community Integrated Care, a not for profit organisation. Bedroom accommodation consists of 38 single and one double bedroom. There are no en-suite facilities. There are day facilities including a lounge, dining room, and conservatory on each unit. There is a large foyer entrance with seated area and separate shared activities room situated off this area. Externally the gardens have been landscaped to provide a sensory garden with raised flowerbeds. The home is situated on a bus route and is close to the town centre and local shopping facilities. It also has its own transport. Fees range from £390 to £530 per week St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on the 13th April 2007 and lasted eight and a half hours. A Regulatory Inspector carried out the visit. This visit was just one part of the inspection. Other information received was also looked at. Before the visit the home manager was also asked to complete a questionnaire to provide up to date information about services provided. Questionnaires were provided for residents, families, and health and social care professionals to find out their views. During the visit various records and the premises were looked at. A number of residents and staff were also spoken with and they gave their views about the service. What the service does well: What has improved since the last inspection? A new care plan format has been introduced which has both pre written and template documents in. This allows staff to identify if additional assessments St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 6 are needed and advises staff on additional information needed in the monitoring of residents’ health and welfare. 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 Catherines Care Home DS0000018740.V333483.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 Catherines Care Home DS0000018740.V333483.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): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for residents and their representatives so they can make a choice about where they live. Residents’ needs are assessed prior to moving in so appropriate care can be provided to them. EVIDENCE: St. Catherine’s accommodates mainly people from the Nantwich area and is welcoming to anyone from outside the area or with a disability, different ethnic or cultural needs or sexual orientation. Residents or their relatives were provided with a copy of the service users’ guide and statement of purpose on request and copies of this and the most recent inspection report were available in each unit. Service user guides were not put in each bedroom. This contained details of the facilities and services provided to residents. Information could be provided in different formats on request to head office. Residents were given a handbook, which provided information on moving in, settling in, care and support, finances, wellbeing, notes on personal care plan and useful contacts. Residents’ surveys returned St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 9 prior to the site visit recorded that residents had been provided with information on St.Catherine’s before the moved in. Two files were examined of residents who moved into St.Catherine’s. The residents had met with the manager or registered nurse to discuss their care prior to moving in. Information was gathered and this was recorded. This included information on their physical and mental health. Copies of these documents were on residents’ files. Copies of social workers assessments and care plans were on file with information from the NHS hospital the residents were staying at. St Catherines Care Home DS0000018740.V333483.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 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Completed records of care, liaison with health and social care professionals and good medicine management ensures residents’ health and welfare needs are met. EVIDENCE: The care files of two residents were examined. Each care plan had a pre admission assessment and an assessment by the social worker or nurse assessor. From looking at care plans, observing staff working practices and talking with residents, staff and visitors residents’ needs were met. There were good examples of care plans in place that monitored residents’ health. Care plans were individualised to each resident. The plans related to medical conditions and gave guidance to staff. Community Integrated Care had introduced a new care plan recording format, a ‘core support plan’, which was being used. This was a mixture of pre written and blank care plans. The pre written care plans formed a library of care plan from which staff could choose the appropriate one to support residents’ needs. The care were individualised to residents. A good example of this was a care plan for diabetes. This gave St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 11 staff advice to follow on monitoring health related problems of diabetes such as monitoring blood sugar and other diabetic associates symptoms. There was a care plan to maximise the independence of residents, which recorded the support residents needed, and their ability to care for them self. There were examples of resident’s families being involved in their care. A resident had been provided with a small aid to assist him getting out of bed. There was no risk to the resident of this being used. Care plans described the level of support residents needed and where staff provided help. There were regular contacts with other healthcare professionals recorded such as diabetic nurse, community psychiatric nurse, psychiatrist, General Practitioner (GP), continence advisor and dietician. Residents’ records also contained monitoring forms for eating and drinking, risk of developing pressure ulcers and assistance with personal care. Good practice in routinely monitoring residents physical health were in place and residents’ blood pressure and weight were monitored. Improvements in the physical and mental health of residents were recorded. Information in these was mainly reviewed monthly and demonstrated improvements in health. This information was generally transferred into care plan reviews but some information was not. The manager acknowledged that in using the new care plan format there were some ‘teething problems’. A survey from a GP returned prior to the site visit recorded, ‘ Excellent nursing home. Staff worked hard with general practice to ensure residents receive the same level of care and health reviews as those able to attend surgery’. Three residents’ surveys returned prior to the site visit recorded that residents always or usually received the medical support they needed. A relative/carer survey recorded, ‘ they respond to day-to-day care and changing needs. Mum had a short spell in hospital recently when she went off her legs. Within hours of her returning she was propped up in bed and staff spending lots of time tempting her to eat, they provided an easy chair on wheels’. Another recorded, ‘we are very happy with the whole ethos and understanding within this care home setting. A very happy place’. Medicines management and administration was examined. Minor errors were noted on medicine administration records. A monitored dosage system was used throughout the care home. Stocks of medicines were replaced monthly. Receipts of supplied medicines were recorded. Where medicines were supplied in original packages and not supplied each month the stocks of these were transferred from one month to the next so staff knew when to reorder medicines. Records were maintained for the destruction of medicines. Controlled drugs records were checked on one unit and no errors found. The deputy manager audited medicines as part of the quality assurance system and found some minor errors but did not record the action taken to rectify the errors found. St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 12 Prior to the site visit the manager informed CSCI of errors made in the administration of medicines by staff. She confirmed that she had monitored staff practice to ensure no further errors occurred but this had not formed part of the development and supervision of staff. St Catherines Care Home DS0000018740.V333483.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, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported in maintaining their independence and making choices about their lifestyle so they have control over their lives. EVIDENCE: St. Catherine’ employs a fulltime activities coordinator and has two volunteer activities staff. There were separate facilities for the provision of activities and activities took place within the individual units. The facilities included a separate kitchen, which residents used, supported by staff. Details of the activities available were displayed on the units with photographs of activities residents had been involved in such as gardening and days out. Residents said there were a variety of planned activities available to them. Social activity care plans were in place and life histories completed for residents by their families. Residents talked about their daily lives and choices they made. Activities taking place during the site visit included a charity ‘pets for therapy’ that visited with dogs that residents could pet. A resident said, “It’s a very sociable place, we’ve been baking today and would have joined in the afternoon activities but I have a visitor”. A visitor said, “ I visit every morning and have breakfast with my friend. This place is a very important part of his life and as his friends we see it as the same. We are welcomed and all our questions are answered”. St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 14 The volunteer worker works four hours a day Monday to Friday. He said, “ I really enjoy working here, it’s a lovely place to visit. I help out and help the residents grow vegetables. I give a hand with activities and make the tea. It’s always friendly and happy”. The activities coordinator discussed activities and said that another activities volunteer helped her two days a week and worked with residents on the two units reading to them or taking them for walks in the garden. The activities coordinator said she worked flexibly to suit residents and the activities budget was not an issue as monies were always available for activities in and out of the building. She said how they supported residents pursue activities and had for one resident invited a local bridge club to come to St. Catherine’s and play bridge with them. The resident’s family said they supported their mother “even to the point of bringing people in so mum can still play bridge”. The home has a minibus it shares with another care home. The activities coordinator said that other care homes within the Community Integrated Care (CIC) group had started to share activities such as visiting entertainers. When an entertainer was visiting another CIC care home they would be invited for a social afternoon or evening. The activities coordinator said that activities coordinators employed by CIC met monthly to share ideas and support one another in developing new ideas. She said “We share the activities programme with two other care homes for external entertainers or interesting groups like a tea dance. We had one on the 11th April and invited residents from the other homes. It worked really well and we are going to continue this”. A relative wrote in a survey of the activities provided ‘St. Catherine’s is an exceptionally good home with excellent activities on offer. Most weekdays the activities coordinator is so kind, happy, patient and so imaginative and creative in the activities she provides”. There were details of a regular church service taking place at St.Catherine’s. Residents and relatives were very complimentary about the standard of food provided. A resident said, “It’s not home but a very good place to stay to provide you with help. The food is very good. You saw me this morning with my cereal, toast and a bacon sandwich. I really enjoyed that”. Another resident said, “ The food is lovely, lots of variety. I can have a cooked breakfast, cereal or what I like. They gave me prunes and fresh fruit when I asked. I would recommend this place to my friends or family”. A relative recorded in a survey that soups were excellent, sandwiches good but too much trifle. St Catherines Care Home DS0000018740.V333483.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are acted on to demonstrate they are taken seriously. An informed staff group and manager protect residents from abuse. EVIDENCE: There was one recorded complaint since the last site visit. This had been investigated using the CIC complaints procedure. There were detailed records demonstrating a full investigation of the concerns raised. The complainants were involved throughout the complaint. The manager used a variety of methods to assist the complainants to confirm their concerns but the complaint could not be substantiated. Residents’ and relatives’ surveys returned said that they knew about the complaints procedure and who to speak to if they had any concerns. A relative survey said, ‘I am sure they always go that extra mile, no complaints from mum or me. We always get an on the spot response as required’. Another said, ’The concerns I have raised have been few and far between’. A referral was made under a local council adult protection procedure regarding a resident at St. Catherine’s. The referral did not concern the standard of care provided at St. Catherine’s. St.Catherine’s cooperated with the local council and supported both the resident and their family during this time. A positive outcome was reached with the resident choosing to remain at the home. St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 16 The registered providers’ corporate induction programme included adult abuse awareness training. All new staff had undertaken training as part of induction and records confirmed this. The manager confirmed that the induction programme was now mainly based in the care home and staff had to complete training on the company’s intranet. There were learning materials for staff to complete including an educational video in the home. CIC’s trainer completed this during the corporate induction programme and records held centrally. The manager said that the training held at St. Catherine’s had not been added to training records. St Catherines Care Home DS0000018740.V333483.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): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable and well-maintained environment, which is equipped to meet their needs. EVIDENCE: St.Catherine’s is set in its own grounds and has its own enclosed garden. There was a sensory garden, which was awarded a gold award by the local council. The grounds were very well maintained and pleasant areas had been provided for residents to sit and walk in. There were vegetable patches for residents to grow their own vegetables. The building continued to be maintained to a very high standard. The two units Meadow and Weaver had their corridors decorated. Bedrooms were decorated as they became vacant. Residents and relatives commented upon the cleanliness of the environment a resident commented that it was “very clean and cared for”. Another resident said, “It’s a lovely place, we share a bedroom with our own furniture so it’s a bit like home. They bring our laundry everyday St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 18 and I put it away”. A relative survey said, ‘ unlike other care homes there is no terrible smells here’. St Catherines Care Home DS0000018740.V333483.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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are adequate to meet residents’ needs. Staff recruitment ensures that residents are protected. The induction and training programme provides a skilled workforce that protects residents’ welfare. EVIDENCE: Staffing levels were appropriate and the manager confirmed that staffing numbers were determined by the dependency of residents and could change. Each unit had an appropriate mix of qualified and unqualified staff. The unit manager on each unit was experienced in the care of the residents for that unit. St. Catherine’s had an excess of registered nurses. Due to this factor they work on the rota providing hands on care to residents along side the care assistants and are included in the numbers of care assistants on each unit. The pre inspection questionnaire returned prior to the site visit recorded that thirteen of the twenty-five care staff employed had an NVQ level 2 qualification. Four staff had commenced employment and had been supervised through an induction programme, which included training on the protection of vulnerable adults. The records of three of them were examined. All contained appropriate identification documentation and completed POVA First and Criminal Record Bureau disclosures. All files had two written references. Files contained copies St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 20 of the induction programme. The personal identification numbers of registered nurses were checked with the Nursing and Midwifery Council. Staff completed the induction programme supervised by the training coordinator. Induction programmes ran on a continued basis until completed due to the use of computer based learning. The training coordinator verified that staff were given timescales for the completion of training and she was able to check individual progress. Information provided in the pre inspection questionnaire verified that staff Criminal Records Bureau disclosures had been updated after three years. Staff had been provided with and had completed a variety of training. This included: a certificate in nutrition for six staff, palliative care for four staff, end of life care for two staff, Macmillan care pathways for six staff, attending an employment conference and cognitive behavioural therapy for individual staff. Training was planned for diabetes diet, palliative care, medicine management, mental illness, defensible documents and communication skills and challenging behaviour. A training record system had been developed which recorded all mandatory training but needed to be further improved to record protection of vulnerable adults training. St.Catherine’s is part of Central and Eastern Cheshire Partnership Trust ‘End of Life Care’ development programme for care homes. As part of this a registered nurse form the home took the lead in the development of palliative care standards within St.Catherine’s. This had lead to staff having training in end of life and palliative care and the use of the Liverpool care pathway. The manager said it had been used on three occasions and had helped involve the residents’ families and GP’s more in providing dignified care for residents. St Catherines Care Home DS0000018740.V333483.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): 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Robust quality assurance systems, financial procedures and maintenance of the building and equipment safeguards residents and ensure they are safe. EVIDENCE: The home manager has been in post for five years. She is a registered general nurse and has the registered manager award. A deputy manager had been appointed who was a registered mental nurse and advised on the care in the dementia care unit. In addition a training coordinator had been appointed to coordinate and plan training and support care and domestic staff through NVQ training. A full time administrator supported the management team. The manager was seen as being pivotal to the running of St. Catherine’s. A relative said, ”I can’t speak highly enough of her and the team they keep me informed of my wife’s condition and she always’ looks well cared for. They have a sense of humour. It’s so nice to see a manager and team that are so outgoing. The St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 22 place is friendly and vibrant. I’m local and everyone I speak to about St.Catherine’s say it’s the best care home for miles around”. Relatives surveys returned prior to the site visit recorded ‘the manager is an excellent communicator. I can’t speak highly enough of the caring approach the staff have to my mum’s changing needs. The staff are extremely professional and fit in with the residents’ choice and not the other way round. If my mum can’t be with me then St.Catherine’s is the best place for her’. Another recorded ‘ very constructive and involved staff. We feel part of the same team. Super staff led from the top. Exactly what we expected from the recommendations’. The manager said in discussion “We don’t stand on our laurels and accept all the plaudits we get. We don’t become complacent, as a team we are always looking for ideas and ways to improve. We never accept were there as you continually have to work at providing high standards”. Another care home manager carried out visits required by regulation 26 of the Care Homes Regulations. The deputy manager was responsible for audits that complimented the quality assurance system. Each month she randomly completed an audit of a small number of care plans and medicine administration records of individual residents. The audits identified errors in the writing and recording of both care plans and medicine administration records. Medicine administration audits did not identify timescales for rectifying errors, or if the matters were discussed with individual staff during supervision. The care plan audits seen identified a number of errors, which had been addressed. As part of the quality assurance system there were audits of accidents, equipment, water temperatures, the building, staffing, sickness, cleanliness and health and safety as some examples. Another care home manager then audits the care home each month using the original data gathered by the manager. There were residents/relatives meetings held at least twice a year. The last meeting took place in November 2006. Heads of department and staff meetings were held at least monthly and included catering and housekeeping. No personal monies other than personal allowances were held on behalf of residents. Relatives were billed directly for additional services such as chiropody or hairdressing. Residents’ personal allowances were safely secured and records for credits and debits maintained. Information provided by the provider in a pre inspection questionnaire and records held on site were examined. All the required maintenance and health and safety checks of the building and equipment had been completed. St Catherines Care Home DS0000018740.V333483.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 4 X 3 X 3 X X 3 St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The outcomes from the auditing of care plans and medicine administration records should clearly specify timescales for the maters identified to be addressed and form part of the ongoing development and supervision of staff St Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Catherines Care Home DS0000018740.V333483.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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