CARE HOMES FOR OLDER PEOPLE
St Catherines Nursing Home 152 Burngreave Road Sheffield South Yorkshire S3 9DH Lead Inspector
Mrs Janis Robinson Unannounced Inspection 10th January 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherines Nursing Home DS0000021809.V274757.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 Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Catherines Nursing Home Address 152 Burngreave Road Sheffield South Yorkshire S3 9DH 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) 0114 272 3523 0114 279 6094 St Catherines Nursing Home 1996 Limited Mr James Kelly Care Home 72 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (41) of places St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users can also be between the ages of 60 and 65. One specific service user under the age of 60 years named on the variation dated 9th May 2005 may reside at the home. 14th June 2005 Date of last inspection Brief Description of the Service: St Catherines is a three-storey building consisting of a converted existing building and a purpose built extension. The home has two units, the converted building caters for up to 31 older people with Dementia. The purpose built extension caters for up to 41 older people. The home provides nursing care for up to 72 people over 60 years of age. The home is set in pleasant gardens in the Pitsmoor area of Sheffield, within easy reach of the city centre and close to local amenities. The home has 48 single and 12 double rooms, each provided with en-suite facilities. Communal lounge and dining areas are provided. There are sufficient bathing facilities, with aids and adaptations in place. The home has a car park. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours from 9.00am to 2pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, menu, rotas, training, supervision, health and safety, recruitment and fire records. The lunchtime meal and interactions between staff and residents were observed. Ten residents, the majority of staff and three visitors were spoken with. Discussions took place with the homes training officer, administrator and manager. What the service does well:
The interactions observed between residents and staff appeared patient and respectful. Residents said most staff were respectful and caring. Some staff were described as `wonderful’, and `staff try their hardest’. The visitors spoken with were happy with the care provided at the home. Each resident was provided with a contract, which informed them of their rights and obligations. Trial visits took place, to enable prospective residents and their representatives to make informed choices. Care plans were in place for all residents. These set out in some detail the personal, social and health care needs of the individual. There was home an open visiting policy, to encourage contact with relatives and friends. The routines at the home were flexible, to enable residents to have some control over their lives. The menu was varied, and choices were offered at mealtimes. Staff were observed to offer assistance with eating to those residents that required this. There was a complaints procedure and adult protection procedure in place, to promote residents safety. On the day of the inspection the environment was clean and odour free. Communal areas contained homely touches to create a comfortable environment. Bedrooms contained personal belongings, which enabled residents to have some control over their personal space. Agreed levels of staff were being maintained. A staff training record was in place. There was a quality assurance system, which sought the views of residents and their representatives. A business plan was in place, and insurance cover was provided. Records within the home were stored securely, to respect confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherines Nursing Home DS0000021809.V274757.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 Nursing Home DS0000021809.V274757.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): 2,3 and 5 Contracts had been undertaken with each resident, to inform them of their rights and obligations. Assessments of needs were undertaken prior to admission to ensure that the needs of prospective residents could be met. Trial visits were encouraged, to enable prospective residents and their representatives to make informed choices. The information available and actions taken ensured that standards were met. EVIDENCE: Statements of terms and conditions were undertaken with residents to ensure that they were provided with information about their rights, those examined contained relevant information and had been signed by the resident or their representative. The manager undertook needs assessments prior to admission, either in the prospective residents own home or in hospital. The information was used to formulate a plan of care to ensure staff knew how to look after the resident. Copies of social workers full needs assessments were obtained prior to admission, if these were available, in order that full information was available. Two care plans examined did not contain the records of the pre admission assessment that had been undertaken.
St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 9 Prospective residents and their families were encouraged to visit the home to meet staff, residents and have a look around the home before admission to inform their choices. Staff confirmed that this was normal practice and residents said their family had looked around the home on their behalf before they decided to move in, if they were ill in hospital. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 and 11 Each resident had a care plan, to ensure his or her opinions had been sought and needs assessed. Further detail and review of the plans was required. Health care needs were monitored and met. Residents’ privacy and dignity was respected. Some care plans did not contain information relating to residents wishes regarding dying and death. EVIDENCE: Care plans were well set out and easy to read. Whilst the plans contained a range of information, and the majority had been reviewed on a monthly basis, some information was not included or up to date. One section of a plan had not been reviewed on a monthly basis, and was potentially out of date. One resident had not signed their care plan, and a further plan checked was only signed in one section. Information on the staff action required to meet assessed needs was not specific. Plans stated ‘staff assistance needed’, but did not detail how this assistance was to be given. Care plans identified health needs, and evidenced that these were monitored. Appointments and treatments with health care professionals were recorded. Assessments relating to nutrition, falls, continence, mobility and tissue viability
St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 11 had been undertaken in order to keep residents as safe as possible. Residents said they were able to see their doctor in private and the staff `took good care’ of them. One resident at the home self-administered medication. Facilities to store this safely had been provided. A written risk assessment to evidence that this had been an informed decision had not been undertaken or signed by the resident. All of the residents said the staff treated them with respect. Comments were`the staff are kind’, and `some staff are wonderful’. The interactions observed between residents and staff appeared patient, reassuring and respectful. Staff were observed knocking on residents doors before entering. Two plans inspected did not contain any information on dying and death. One resident freely and spontaneously shared their wishes regarding funeral arrangements with the inspector, yet none were recorded in their care plan. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 12 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): 13 and 15 An open visiting policy was in operation, to develop and maintain good relationships with family and friends. A varied menu was provided, and choices were offered to residents to respect their preferences. EVIDENCE: Residents confirmed that they were able to see their visitors in private, and their family could visit at any time. The three visitors spoken with confirmed that they were able to visit at any time. They said that they were `very happy’ with the care provided at the home, and had no concerns. The menu provided to residents was varied and a balanced diet was offered to respect individual choices and maintain health. Staff were observed offering assistance with eating to those residents that required this support with patience and respect. Special diets were catered for. All of the staff and residents said that choices were offered at mealtimes, and food was available at all times. Residents said `the food is very good’, and `I can choose what I want’. Drinks and snacks were offered throughout the day. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An adult protection procedure was in place, to ensure residents safety was promoted. EVIDENCE: The complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. Residents said that staff would listen to any worries they had. Staff were confident in the homes manager to take any complaints seriously. No complaints had been received by the home since the last inspection. There was an Adult Protection policy in place, this had been updated to include the Department of Health guidance `No Secrets’ to ensure staff had access to all of the information needed to promote residents safety and well being. All of the residents said that they felt safe at the home. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24 and 25 The home was clean and generally well maintained. Homely touches had been provided to create a comfortable environment. Bedrooms were well decorated and personalised, in the main. Sufficient bathing facilities were provided. Aids to meet the moving and handling needs of residents were in place. Some bedrooms had minor damage to the decoration. The lounge carpets in both units were stained. The central laundry and kitchen were well equipped, to meet residents needs. EVIDENCE: Since the last inspection the corridor area in one unit, and several bedrooms had been redecorated to improve the environment. All of the residents said the home was comfortable and they were happy with their rooms. Some bedrooms had slight damage to the decoration, and all of the lounge carpets seen were stained and marked. Some corridor areas had damaged decoration, and some corridor carpets were stained. A ceiling in the corridor in Carregaffe unit had a leak. Two lounges in the Tibohin unit had uneven and
St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 15 slightly unstable flooring, posing a possible hazard. Dining furniture in the Carregaffe unit was worn and in need of replacement. Bedroom doors were fitted with locks and residents were provided with keys if they were assessed as able to safely manage this. Each bedroom was provided with a lockable facility to store personal belongings. Residents were able to control the heating in their rooms. The majority of bedrooms were provided with en-suite toilet facilities. Sufficient bathing facilities were provided and aids and adaptations were in place to meet residents moving and handling needs. One bathroom floor in Carregaffe unit was badly marked. The laundry was sited away from food preparation areas, ensuring safe practices were followed. Procedures were in place for the control of infection to promote residents safety. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 29 Agreed levels of staff were being maintained. Agency staff were used to cover a number of duties. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff had not been achieved. The homes recruitment practices required some additions, to ensure a thorough procedure was in operation. EVIDENCE: The rota indicated that agreed levels of staff were being maintained to meet the needs of residents. However, the rota indicated that agency staff were used on a number of shifts to maintain staff numbers. Agency staff covered six shifts during the week of the inspection. The inspector acknowledges that attempts to recruit further care staff were taking place. Residents felt that enough staff were provided. NVQ training was provided to some staff. Of the 30 care staff, 7 staff had achieved NVQ level 2 in care, a further 3 staff had commenced the training. This did not meet the recommended 50 of the care staff trained to NVQ level 2 in care by 2005. Whilst the staff files inspected contained all of the information required to ensure safe practices were undertaken, staff photographs were not kept for all members of staff. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 17 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): 33,34,35,36,37 and 38 A quality assurance system was in place, to seek the views of residents and their representatives. Residents’ finances were safely managed. Formal staff supervision to develop and support staff, did not take place at the required frequency. Records were stored securely, to respect residents’ rights. A business plan and insurance cover was in place. A health and safety policy was in operation, to promote safe practices within the home. Systems were checked and serviced. Some staff mandatory training was out of date EVIDENCE: Surveys with residents and/or their families and their relatives were undertaken, to obtain their views and inform practice. Monthly visits and reports were not undertaken by the registered provider, to ensure the home was effectively monitored.
St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 18 Residents’ finances were managed and audited. An `arms length’ account was in operation. Residents’ monies were banked and individual interest paid. Records of spending were maintained. An accountant undertook annual audits. Staff supervision, to develop, inform and support staff did not take place at the required frequency of six times each year. Records were stored securely in the home to respect residents’ confidentiality. A health and safety policy was in place to protect staff and residents. All fire exits were clear and fire doors closed on their rebates. Records evidenced that water temperatures and fire equipment was checked and serviced. Some staff were up to date with all aspects of mandatory training to equip them with the basic skills needed to promote the well being of residents. However, records indicated that some staff required refresher training in moving and handling, and food hygiene. Whilst staff fire instruction had taken place at a regular basis, a minority of staff had not participated in the training at the required frequency. Practice fire drills were not recorded or identified on the staff training plan. As a result, staff participation in fire drills was difficult to monitor. One wheelchair seen did not have a footplate. Staff reported an insufficient number of wheelchairs provided at the home to meet residents’ needs. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 2 3 X 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 3 2 St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 31/03/06 2 3 OP7 OP7 15 15 Records of pre admission assessments must be available and maintained alongside other relevant records. Where able, residents must sign 31/03/06 care plans. (Previous timescale of 1/09/05 not met) Care plans must contain specific 31/03/06 detail on the staff action required to ensure assessed needs are met. All sections of care plans must be reviewed on a monthly basis. Written risk assessments and signed agreements must be undertaken when residents selfadminister medication. (Previous timescale of 1/09/05 not met) Residents’ wishes regarding funeral arrangements must be sought and recorded. Where this information has been refused, or is to be provided by representatives at appropriate times, this must also be recorded. All rooms with damaged or
DS0000021809.V274757.R01.S.doc 4 OP8 13 31/03/06 5 OP11 12 31/03/06 6 OP19 23 31/03/06
Page 21 St Catherines Nursing Home Version 5.1 7 OP19 23 8 9 10 OP19 OP19 OP20 23 23 23 11 12 13 14 OP21 OP27 OP29 OP33 23 18 18 26 15 OP36 18 16 OP38 13 17 OP38 13 18 OP38 13 stained decoration must be redecorated. (Previous timescale of 1/05/05 and 1/09/05 not met). All damaged and stained carpets must replaced. (Previous timescales of 1/05/05 and 1/09/05 not met) The worn dining furniture must be replaced. The leak in the corridor in Carregaffe unit must be investigated and repaired. The warped flooring in the quiet room and lounge in Tibohin unit must be investigated and repaired. The damaged bathroom flooring in Carregaffe unit must be replaced. Care staff must be employed in sufficient number to cover the rota. Staff files must contain a photograph (previous timescale of 1/09/05 not met). Monthly provider monitoring visits must be undertaken and a copy of the report forwarded to the local office of the CSCI. Staff must receive formal supervision at the required frequency of 6 times each year (Previous timescale of 1/09/06 not met) Any identified gaps in training must be provided. All staff must have up to date training in Moving and handling and Food Hygiene (Previous timescale of 1/09/05 not met). Wheelchairs must be serviced and maintained in good working order. Sufficient wheelchairs must be provided to meet the needs of residents. Records of staff fire drills must
DS0000021809.V274757.R01.S.doc 31/03/06 30/04/06 31/03/06 31/03/06 31/03/06 31/03/06 30/04/06 30/04/06 31/03/06 31/03/06 31/03/06 31/03/06
Page 22 St Catherines Nursing Home Version 5.1 be maintained and monitored. All staff must participate in a practice drill a minimum of twice each year. 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 OP28 Good Practice Recommendations 50 of the staff team must be trained to NVQ level 2 in care by 2005. St Catherines Nursing Home DS0000021809.V274757.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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