CARE HOMES FOR OLDER PEOPLE
St Catherines Home 146 Southcoates Lane Hull East Yorkshire HU9 3AJ Lead Inspector
Malcolm Stannard Unannounced Inspection 13th January 2006 10:30 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 Home DS0000000872.V278340.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 Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Catherines Home Address 146 Southcoates Lane Hull East Yorkshire HU9 3AJ 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) 01482 375164 01482 718139 The Trustees of the Institute of the Sisters of Mercy Sister Brendan Carabine Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32) of places St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: St. Catherines is owned by The Institute of the sisters of Mercy and managed by Sister Brendan Carabine. A registration is held to provide accomadation and personal care for up to 32 adults over the age of 65 of either gender, who may also suffer from dementia. St Catherines is set in its own grounds to the east of the city of Hull. There is ample provision of car parking and public transport is easily accessible. A range of health, social and leisure services are nearby. Accomadation is on three floors, with all 32 rooms offering single provision, 20 rooms have en-suite facilities. Communal areas include a tea bar on each floor, large dining room and a common room. A small smoking lounge and hairdressing room are also available. The home has its own chapel which forms a part of the main building. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three and a half hours. Some parts of the building were looked around and a few of the records were inspected. Two rooms were viewed, which the trustees are considering converting into bedrooms and increasing the number of people who may be cared for to 34. This change must be dealt with as a variation to the registration. The focus of this visit was to address any requirements or recommendations outstanding from the last inspection. Some of the residents were spoken with, and two visitors were chatted with. The manager was available during the inspection. What the service does well: What has improved since the last inspection?
St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 6 The homes management now ensure that photographic evidence is available on staff members files; this enables all individual staff to be identified with their paper identity evidence. Accident records are now held using a loose-leaf system, which enables any data protection, needs to be met. Individual accident records are placed upon individual residents files following completion. 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. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 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 Home DS0000000872.V278340.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. The pre admission procedure ensures that a proper assessment can be carried out; this process means that residents and relatives can be sure that the home will meet their needs. EVIDENCE: One of the deputy managers carries out a pre admission assessment either at the prospective residents home or in hospital. A senior staff member also attends on occasions. The assessment of needs is discussed with the home manager and a decision made as to whether the home is able to meet those needs. The prospective resident would be informed in writing. The home does not offer intermediate care. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 9 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): 9. The homes systems for medication administration enables residents to be protected. Where appropriate residents are able to be responsible for their own medication. EVIDENCE: The home utilises the Nomad system of drug storage and administration. Only senior staff members administer medication following undertaking appropriate training. The homes management are able to access advice from the pharmacy, as well as receiving monitoring visits. Any person who wishes to self medicate is risk assessed and advice from the persons GP is taken. A lockable provision for storage of medication is then made available. A written policy and procedure is available for guidance in relation to medication storage, administration and recording. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 10 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. A range of recreational activities is provided in the home and resident’s preferences are respected. Daily choice for residents is enabled and contact with friends, family and within the local community is encouraged where appropriate. EVIDENCE: An activities coordinator is employed on a part time basis; she encourages and enables residents to take part in a range of activities. External trips are undertaken in the warmer months with internal activities such as bingo, movement classes, art groups etc taking place. Residents are able to choose whether they wish to take part in activities or just chat or read on their own. Visitors to the home are encouraged, two ladies who were visiting said that they are always made welcome and offered a cup of tea should they wish one. Over the lunch time period the serving of a ladies meal who was receiving a visit was handled sensitively and with dignity by a staff member. One lady showed me her life book which contained photographs following her life through childhood, marriage etc. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 11 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): None of the above standards were assessed on this occasion. All of these were met during the previous inspection. EVIDENCE: St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 12 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, 23, 24, 25 & 26. The home provides a safe, comfortable and clean environment for residents, which is homely and pleasant. Rooms available meet the needs of individual residents. EVIDENCE: The home continues to be well maintained, with all areas being well presented in a hygienic fashion. Domestic staff are employed to ensure the presentation is consistent. Any maintenance work required is carried out as necessary with a record been held of all work carried out. Residents rooms viewed were suitable for all individuals’ needs, with a large amount of personal processions been apparent in bedrooms, including chairs etc. All rooms are capable of being secured unless this is considered unsafe or the individual resident declines a key. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 13 Risk assessments are available for all areas of the home, which identify all areas where there may be a risk of harm to staff or residents. All checking of major services such as electrical systems and fire alert/prevention systems is carried out by contractors under maintenance agreements. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 14 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): 29. Protection is ensured for the residents in the home by the selection and recruitment procedures. EVIDENCE: All recruitment requirements as required by the standards and regulations are carried out prior to any employment of staff in the home. References, CRB and Pova 1st checks are undertaken and health declarations are requested. The management follow up any inaccuracies identified with the staff member concerned. Evidence of qualifications and identify is held on an individual staff members file, this now includes photographic evidence of a staff members identity. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 15 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 & 38. The management of the home is carried out in leading by example manner. The home is resident centred and all health and safety needs are protected. The gaining of a management certificate by the manager would enhance the leadership quality. EVIDENCE: The manager is a qualified nurse, however she does not hold a management certificate. The holding of this qualification to a level equivalent to a level 4 NVQ is now a requirement. The manager explained however that she plans to move from the home in the near future so did not plan to commence a qualification course. The manager attends care practice training sessions along with the staff members.
St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 16 The home carries out it’s own internal quality audits, it would be beneficial if information gained from resident’s and relative’s surveys was collated and the results published. The manager explained that they were considering publishing these in a prospectus. A local authority quality development provision is also held. Records are held of all accidents, which take place in the home, the home now uses a data protection act compliant record book and all accidents are recorded on resident’s individual files. Resident’s health and safety is protected by regular checking of all equipment and maintenance carried out by external contractors. Fire drills and testing of the fire detection system are carried out and recorded appropriately. St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 3 St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 18 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. 1 Standard OP31 Regulation 9 Requirement The registered manager must hold a management qualification, which is equivalent to an NVQ level 4. The course must be commenced by the date given for action. Timescale for action 15/04/06 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 OP33 Good Practice Recommendations Information received from resident and relative surveys should be collated by the home and the results published St Catherines Home DS0000000872.V278340.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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