Inspection on 26/04/07 for St Catherines Home

This inspection was carried out on 26th 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 Home 13/01/06

St Catherines Home 01/03/05

St Catherines Home 13/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Catherines Home 146 Southcoates Lane Hull East Yorkshire HU9 3AJ Lead Inspector Diane Wilkinson Unannounced Inspection 26th April 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 Catherines Home DS0000000872.V337822.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 Home DS0000000872.V337822.R01.S.doc Version 5.2 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 Our Lady of Mercy Margaret Audrey Jackman Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34) of places St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: St Catherines is owned by The Institute of Our Lady of Mercy. It is registered to provide accommodation and personal care for up to 34 adults over the age of 65 of either gender, including those with dementia. Information about the home is provided to service users and others in the home’s statement of purpose and service user guide. Although the home is owned by a Catholic religious order, people of other faiths (or no faith) are welcome to move into the home. St Catherines is situated in the east of the city of Hull. It is a large property that is set in its own grounds, and there is ample car parking space. It is close to public transport and to local amenities such as shops, banks and cafes. Fees paid range from £293.50 to £327.50 per week and there is an additional charge for hairdressing, private chiropody, toiletries and newspapers. Accommodation is provided over three floors; private accommodation comprises of 34 single bedrooms, twenty-two of which have en-suite facilities. Communal areas of the home include a tea bar/lounge on each floor, a large dining room and a lounge. A small smoking lounge and a hairdressing room are also provided. All areas of the home are accessible to service users via the provision of a passenger lift. The attractive garden has been specially designed to meet the needs of the people living at the home and is easily accessible. The home has its own chapel which forms a part of the main building. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire completed by the registered manager, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home (including surveys) and from the site visit on the 26th April 2007. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 9.45 am and finished at 4.20 pm. The site visit consisted of a tour of the premises and examination of documentation, including five care plans. On the day of the site visit the inspector spoke on a one to one basis with three residents, three members of staff, the registered manager and the area manager. Surveys were sent out to 34 service users, 36 members of staff, 34 relatives and seven health and social care professionals. Nine were returned from service users, six from staff, 17 from relatives and two from health and social care professionals. Feedback about the responses received in surveys was given to the registered manager (anonymously) on the day of the site visit. Comments from discussions with service users and others, and respondents in surveys, will be included throughout the report (anonymously). The inspector would like to thank service users, staff, the registered manager and the area manager for their assistance on the day of the site visit, and to everyone who spoke to the inspector or responded to a survey. What the service does well: Service users are assessed prior to their admission to the home and only offered accommodation if their assessed needs can be met. The personal care needs of service users are met in a way that respects their privacy and dignity. One relative said, ‘The staff are always very sensitive to my mother’s need for privacy’. Service users and relatives express satisfaction with the care provided by staff at the home and speak highly of the staff group. Spiritual care is especially good. Service users are supported and encouraged to be as independent as possible, and to continue to live their chosen lifestyle. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 6 There is a robust system in place for the administration of medication that protects the safety and well being of service users. St Catherines provides a pleasant homely environment for the people who live there with high standards of cleanliness throughout the home. Staff are well trained and supported. Managers and staff have a good understanding of the needs of service users which assists in their assessed care needs being met. 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 Catherines Home DS0000000872.V337822.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 Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are only admitted to the home following a needs assessment that evidences that their current care needs can be met. EVIDENCE: The inspector examined the records for two newly admitted service users. These included a full needs assessment, a medical profile, a social profile and a record of daily living needs. When service users are funded by the local authority, a copy of a community care assessment and care plan is also obtained from Care Management. Service users told the inspector that they visited the home prior to their admission; in some instances the home was already known to them and in other instances service users initially stayed at the home for respite care. One St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 9 service user stated in the survey, ‘I was not obliged to make a final decision until I had been here a few weeks’. The registered manager told the inspector that service users are only admitted to the home if their needs assessment indicates that their specific care needs can be met. She gave examples of when a place has not been offered to prospective service users following their initial assessment. Two relatives commented that staff are not specially trained to care for service users that have dementia. This is being addressed by the registered manager; staff that have not already attended a training programme about challenging behaviour and dementia will do so shortly. St Catherines Home DS0000000872.V337822.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are met in a way that respects their privacy and dignity. EVIDENCE: The inspector examined five care plans; these included a copy of the home’s own assessment and a community care assessment and care plan undertaken by the local authority Social Services Department, where appropriate. Care records included a moving and handling risk assessment that identified any risk of falls. The registered manager has now completed a new care plan for each service user although there are still some ‘old style’ care plans in care records. Key workers record a monthly summary of the care provided to each service user, although some of these have lapsed recently. The registered manager was already aware of this and assured the inspector that monthly reviews of the care plan would be reinstated. Some service users have had a St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 11 meeting to formally review the content of their care plan; this applies to both privately funded service users and those funded by a local authority. A record is kept of all contact with health care professionals; the inspector recommends that these be expanded to include the reason for the contact and any outcome. In surveys, one service user stated, ‘I am very happy with the care and support I receive’. One relative stated, ‘The quality of care is generally excellent but on a few occasions I have found my mother without access to her bell, and unable to summon attention’. A new call bell system was being fitted in the home on the day of the site visit; this is a wireless system that will allow service users to summon assistance wherever they are in the home or grounds. Relatives reported in surveys that they are kept informed of important events regarding their relative and that they feel confident that their relatives are receiving the best of care. The responses from health care professionals were positive; a GP stated that ‘this is the best care home in Hull’. Continence care and pressure care are promoted at the home. A service user’s individual needs regarding continence care and pressure care are recorded in assessments and care plans, and reviewed appropriately. Some service users have been provided with special pressure care equipment such as mattresses and cushions. The inspector examined medication records and storage arrangements; both were satisfactory. The arrangements for the storage, administration and recording of controlled drugs are satisfactory. A special fridge for the storage of medication is in use, and temperatures are recorded appropriately. The inspector observed medication being given to service users – all were provided with a drink with which to take their medication. All service users were observed by staff to ensure that they actually took their medication. Medication is returned to the Pharmacist as required and the inspector noted that excessive stocks of medication are not held at the home. The registered manager informed the inspector that the Pharmacist signs a receipt for returned medication at the chemist but there is no ‘returns book’ in operation; this had already been identified by the senior carer responsible for the management of medications in the home, and a book has been purchased for this purpose. This needs to be put into use as soon as possible. The pre-inspection questionnaire submitted to the Commission for Social Care Inspection (CSCI) prior to the inspection recorded that all staff that administer medication have undertaken accredited training; this was confirmed on the day of the site visit in individual training records seen by the inspector. On the day of the site visit the inspector observed that staff treat service users with respect and that their privacy is maintained as far as is possible; service users were assisted with eating their meals and with personal care in a sensitive manner. This was confirmed by service users on the day of the site St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 12 visit and by relatives and service users in surveys. One relative said, ‘The staff are always very sensitive to my mother’s need for privacy’. St Catherines Home DS0000000872.V337822.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities and are encouraged to be as independent as possible; visitors to the home are made welcome. Spiritual care at the home is particularly good. Service users express satisfaction with meals provided by the home. EVIDENCE: The inspector observed that all care plans include details of a person’s previous lifestyle and daily routines. This includes information about likes and dislikes and specific interests. Service users confirm that they are able to exercise their choice in relation to routines of daily living including where to spend their day, where to take their meals and about taking part in social activities. Two of the Sisters from the attached convent assist with activities; one arranges a weekly bingo session and the other plays the piano for residents to have a ‘sing along’. There is a hairdressing room and a hairdresser visits the home every week. However, one service user said, ‘I would like more activities like playing cards’. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 14 Some residents attend mass every morning in the homes chapel and they tend to stay downstairs until lunchtime. Most then return to their rooms to spend the afternoon as they choose - activities include reading, letter writing, watching the TV, listening to music or seeing visitors. There are very pleasant gardens surrounding the home and some service users like to take a walk in the grounds. A GP recorded in a survey when asked what the home does well said, ‘Everything, especially spiritual care’. A relative said, ‘The home specifically meets religious needs of my mother who is a devout Catholic – they have a chapel on site and she is able to attend daily mass’. The philosophy of the home results in a calm and relaxing atmosphere within the home. The inspector observed that service users were supported and encouraged to maintain their level of independence and to live their chosen lifestyle. Some service users had a visitor on the day of the site visit and the inspector observed that they were made welcome by staff. A relative said in a survey, ‘St. Catherine’s is not a regimented home, the atmosphere is relaxed and comfortable. Visitors are always made to feel welcome’. The inspector observed that service users’ rooms have been personalised to an extent chosen by them and some have brought belongings from home to decorate their room. Service users are supported to handle their own financial affairs and the registered manager told the inspector that they are able to refer people to advocacy services should this be required. All service users have a single room and this enables them to see visitors and others in private. Some service users have had a telephone installed in their bedroom so that they can maintain contact with friends and relatives. Some have had satellite TV installed so that they are able to watch their favourite TV programmes. The registered manager told the inspector that most service users have breakfast in their own room. The inspector observed the serving of lunch and noted that service users had a choice of two main meals; a menu is displayed in the dining room. Some service users choose to take meals in their room but most have their lunch in the dining room; staff provided service users with a relaxed and pleasant atmosphere so that they could enjoy their lunch at a leisurely pace. The inspector observed that service users were assisted appropriately to eat their meals. All service users told the inspector that meals at the home are very good and that there is always a choice available. One service user said, ‘I have put on quite a lot of weight since I came. The meals are excellent. The inspector observed that service users were provided with drinks in their bedrooms and that some service users had fruit and other snacks in their bedrooms. The home’s action plan records that the dining room is due to be refurbished and the registered manager told the inspector that they plan to make the St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 15 dining room more like a restaurant, so that it is a more pleasant environment for service users to take their meals and meet friends. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are appropriate systems in place to deal with complaints from service users and others, who feel that their complaints would be listened to and acted upon. Most staff are aware of and follow safeguarding adults policies and procedures; this protects service users from the potential to be abused. EVIDENCE: The inspector examined the complaints book; this records details of any complaints and the outcome of the investigation. The complaints book has recently been replaced by a complaints form – the inspector saw one that had been completed. This records the outcome of the investigation and is signed by the complainant. The form gives complainants the opportunity to state that they are not satisfied with the outcome and that they wish to take the matter further, i.e. to the Area Manager or the CSCI. The inspector recommends that the contact details of the CSCI be added to the form. In addition to the complaints form, the home uses a niggles/concerns book and provides a suggestion box. The majority of relatives that returned a survey said that they knew how to make a complaint, but that they have never needed to do so. However, one relative recorded on the survey, ‘If I have raised any concerns regarding mum’s care it is usually dealt with quite quickly but occasionally I do have to mention things a few times’. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 17 The inspector examined the policies and procedures on safeguarding adults; these are designed to protect service users from all types of abuse. Most staff have attended safeguarding adults training and the registered manager informed the inspector that there are plans in place for all staff to undertake this training. Staff have also attended challenging behaviour and dementia training – this is designed to assist staff in understanding how to deal with these behaviours. Over 50 of care staff have achieved NVQ Level 2 or above in Care – this award includes training on safeguarding adults. However, it was evident in responses recorded in staff surveys that some staff do not have a full understanding of safeguarding policies and procedures, including whistle blowing. This should be addressed when the remaining staff undertake appropriate training. An allegation was received by the CSCI regarding concerns about one service user – this was referred to the local authority Social Services Department under safeguarding adults protocols. The CSCI received a response from the Social Services Department following their investigation stating that they and medical staff felt that there were no grounds to proceed with this allegation, and that there was evidence that the service user had received appropriate medical attention. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides service users with comfortable and well-maintained accommodation. Domestic staff are employed in sufficient numbers to ensure that communal and private areas of the home are always clean and hygienic. Laundry facilities are satisfactory. EVIDENCE: The home is comfortably and attractively decorated and furnished, and is well maintained. The grounds are kept tidy, safe, attractive and accessible to service users and allow ample access to sunlight – the lounge, dining room and bedrooms look out over garden areas. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 19 The inspector examined an action plan dated August 2006 to December 2007 and this included plans for the dining room to be refurbished, wall lights to be fitted in corridors ‘to make the environment more homely’, the lift to be refurbished and the Fire Risk assessment to be reviewed. On the day of the site visit a new call system was being installed – this is a wireless system that allows service users to activate the call system wherever they are sitting in their room, and also when using the grounds. This may encourage more service users to use the gardens, as they will be able to alert staff should they need to do so. The gutters were also being cleaned out and painted on the day of the site visit. A handyman and a gardener are employed by the home and this enables day-to-day maintenance to be carried out efficiently for the safety and comfort of the residents. The registered manager informed the inspector that the home had identified that the central heating and water heating systems in the home needed to be updated and that this work was carried out in the summer of 2006. This work included the re-calibration of mixer taps and shower valves to control water temperatures and reduce the risk of scalding to service users. Currently, some service users are not able to control the temperature of the radiator in their own room; work to rectify this is due to be carried out this summer when it is hoped that service users will not be disrupted by radiators not working on a temporary basis. A relative stated, ‘Some areas could do to be redecorated’. The registered manager intends that bedrooms will be redecorated whenever they become vacant. The home was clean, hygienic and free from offensive odours on the day of the site visit; domestic staff are employed to ensure that hygiene standards are maintained. Laundry facilities are satisfactory and a new tumble dryer has been installed; there are plans in place to further improve laundry facilities. The laundry room is situated away from communal and private accommodation to reduce the risk of cross infection. Staff have undertaken training on infection control. One relative said, ‘the whole place is very clean’. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Well-trained staff are employed in sufficient numbers to ensure that the needs of service users accommodated at the home can be met. Recruitment practices are now robust and fully protect service users from the potential to be abused. EVIDENCE: There is a satisfactory staff rota in place that records the role of each member of staff. The registered manager believes that there are sufficient staff on duty to meet the needs of service users. However, some relatives did record in surveys that more staff are needed due to the increased frailty of some service users. (See further comments in Staffing section). There is a cook on duty each day as well as a kitchen assistant, and there are one or two domestic staff on duty each day. This enables care staff to concentrate on assisting service users with personal and social care activities. There is a separate rota for night staff – this records that there are two staff on night duty and that an additional ‘sleep in’ staff member is arranged if required. It also records the name of the manager who is ‘on call’ overnight. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 21 Some relatives and service users mentioned in questionnaires the high number of agency staff used by the home. One relative stated, ‘Sometimes agency staff are brought in and I feel that they don’t always understand or acknowledge the high level of care administered by staff’. The management team at the home are aware of these concerns and are in the process of recruiting permanent staff. Prospective staff have been interviewed and selected and they are waiting for references and CRB checks to be received. The registered manager informed the inspector that a decision had been made that four care staff plus a senior carer or manager were needed throughout the day and the only way they can meet these staffing levels at the moment is by using agency staff. The agencies used by the home do try to send the same staff so that they become familiar with the needs of service users. The registered manager added that the home did recruit some new staff in October 2006 but they have since left the home. The registered manager intends to advertise for staff for a ‘relief bank’ so that this situation does not arise again. The pre-inspection questionnaire completed by the registered manager records that 50 of care staff have achieved NVQ Level 2 in Care or above; three staff have achieved NVQ Level 3 in Care. This was confirmed on the day of the site visit in training records seen by the inspector. The inspector saw evidence on the day of the site visit that the recruitment and selection of staff is undertaken in a safe manner. An application form is used and this records the employment history of applicants so that any gaps in their employment can be explored. Two written references and a satisfactory CRB check are obtained before staff commence work at the home. Induction training at the home is provided by a private training company – the inspector saw evidence that this company use a Skills for Care training programme. There is a training and development plan in place that records that all staff undertake core training and that some staff undertake more specialised training such as Challenging Behaviour and Dementia and Palliative care. Staff records include information about individual training achievements and a copy of training certificates is retained. The inspector noted that staff have refresher training as appropriate to ensure that their skills and knowledge are kept up to date. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed. The health, welfare and safety of service users and staff are protected, with the exception of some doors that were held open using unauthorised means. EVIDENCE: The registered manager has achieved a post-graduate certificate in management and is a registered general nurse. She keeps her practice up to date by reading information on the Internet and by attending training courses alongside staff. One relative recorded in a survey, ‘the new management team seems to be causing some tensions with staff’. Six surveys were returned St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 23 from staff; four recorded that they receive support and direction from management whereas two reported otherwise. There was no evidence of any disharmony or dissatisfaction on the day of the site visit to the home and this was not raised as an issue by any other relatives or service users. The management team should note these concerns, as any disharmony amongst the staff group could affect the well being of service users. Policies and procedures are being updated and entered into a ‘document control system’. This records when policies have been updated and when the next review is due. A new care tracking system is to be introduced – this is a system that will score the success of care practices within the home and will identify any shortfalls or needs for improvement so that they can be addressed by the management team. Questionnaires have been sent out to service users but this process was suspended when CSCI surveys were sent to service users to avoid confusion. The registered manager has started to produce a quarterly newsletter and intends to include the outcome of any surveys in this publication. When these systems are fully operational service users and others will be able to affect the way in which the service is operated. Staff meetings and service user meetings are held – minutes of these meetings were seen by the inspector. The minutes of the most recent service user meeting record that service users were told about the new call system that is being installed; this will record response times and will allow any delays to be investigated by managers. One relative commented in a survey, ‘I feel that a more secure way of keeping resident’s money is needed and if relatives are involved, a better way of letting them know if more money is required for chiropody etc. I never seem to know what the balance of mum’s pocket money is or where it is, for that matter’. The safe holding of monies by service users has already been identified as an issue by the home. A cash box has been purchased for each service user, and each cash box has been fitted with a different key. These are to be put into use as soon as relatives have been consulted/advised. The inspector checked records and monies held on behalf of service users and found these to be accurate. The registered manager informed the inspector that this information is available to service users and relatives (if appropriate) at all times. The CSCI have been informed previously by the registered manager that a number of thefts have occurred at the home; these have involved monies belonging to service users and staff. The registered manager informed the inspector (and information was seen in meeting minutes) that the community police officer attended a staff meeting to warn staff that the culprit would be found and to advise staff on security issues. The registered manager said that there have been no thefts since this visit. Service users that completed a survey or spoke to the inspector did not express concern about these incidents. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 24 In house fire alarm tests are carried out every week and fire training/drills are carried out on a regular basis. Evidence that the fire alarm system and fire extinguishers are serviced by a contractor annually was seen by the inspector. The inspector noted on the day of the site visit that some bedroom doors have been fitted with automatic door closers that are connected to the fire alarm system. However, some bedroom doors were still being held open with wooden door wedges; this poses a risk in the event of fire. Door wedges must not be used; alternative means of holding open doors must be found if service users wish to have them open. The registered manager agreed that door wedges would no longer be used and that action would be taken within 28 days of the site visit to find alternative means of holding open doors. There is an electrical installation certificate in place, the passenger lift and hoists have been serviced on a regular basis and there is a current gas safety certificate in place. Staff undertake training on health and safety topics and the registered manager has provided a written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments. This is designed to protect the health, welfare and safety of service users and staff. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 X X 2 St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 26 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 OP38 Regulation 13 Timescale for action Unauthorised means must not be 26/04/07 used to hold open bedroom doors, as this poses a risk in the event of a fire. Requirement 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 OP7 OP8 OP9 OP16 Good Practice Recommendations Monthly reviews/summaries of care plans should be maintained consistently. The records held detailing visits from health care professionals should be expanded to include details of the contact and any outcome. The book to record any medication returned to the Pharmacist should be put into use as soon as possible. The complaints form should include contact details for the CSCI. St Catherines Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Home DS0000000872.V337822.R01.S.doc Version 5.2 Page 28 - 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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