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Inspection on 14/06/05 for St Catherines Nursing Home

Also see our care home review for St Catherines Nursing Home for more information

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home 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`. A service user guide had been provided to each resident to give him or her information about 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, and the staff action required to ensure these needs were met. A system for the safe storage and administration of residents` medication was in place. A care worker had been identified as having responsibility for organising activities, and all residents said they enjoyed the activities provided. 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. It was well decorated, in the main. 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. Sufficient bathing facilities were provided to ensure residents personal care needs were met. The central laundry and kitchen were well equipped to meet residents` needs. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. 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.

What has improved since the last inspection?

Since the last inspection residents care plans had been updated to ensure up to date nutritional assessments were in place. Medication was stored securely to keep residents safe. The Adult Protection policies had been updated to ensure the home had all of the relevant information required. Some staff had undertaken training in COSHH (Control of Substances Hazardous to Health), first aid, food hygiene and fire instruction to keep them up to date. A member of care staff had been allocated responsibility for activities within the home, to improve choices to residents. Systems for supervision had been reorganised in an effort to ensure all staff were supervised at the required frequency. A proportion of bedrooms and a corridor area had been redecorated to maintain the environment. The recruitment procedures included exploring gaps in employment history at interview, to ensure thorough procedures were followed.

What the care home could do better:

The care plans required auditing to ensure they contained up to date and relevant information on all aspects of health, social and personal care needs to ensure residents needs were addressed and met. Written agreements and risk assessments had not been undertaken for residents that self-administered medication, to promote safe practices. Sufficient cutlery had not been provided to one resident to help them eat their meal. Lounge carpets in both units were stained, some bedrooms had slight damage to the decoration. One bathroom was used to store two large easy chairs. Staff files did not contain all of the information required to ensure safe recruitment procedures were adhered to. Whilst the home had re-organised the procedures for staff supervision, these were not taking place at the required frequency to ensure staff had appropriate support. Some staff required refresher training with aspects of mandatory training, including food hygiene, first aid, moving and handling and fire instruction.Some residents were moved in wheelchairs without footplates in use. Written risk assessments to evidence that this was in response to identified need had not been undertaken. Several air fresheners and cleaning sprays, belonging to a resident, were insecurely stored in one lounge, potentially compromising the safety of residents.

CARE HOMES FOR OLDER PEOPLE St Catherines Nursing Home 152 Burngreave Road Sheffield South Yorkshire S3 9DH Lead Inspector Janis Robinson Unannounced 14 June 2005 8:30am - 3:00pm 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 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 J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Catherines Nursing Home Address 152 Burngreave Road Sheffield S3 9DH Telephone number Fax number Email 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 2723523 0114 2796094 Not known St Catherines Nursing Home 1996 Limited Mr James Kelly N Care Home with Nursing 72 Category(ies) of OP Old age - 41 registration, with number DE(E) Dementia - over 65 - 31 of places St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users can also be between the ages of 60 and 65. 2..One specific service user under the age of 60 years named on the variation dated 9th May 2005 may reside at the home. Date of last inspection 11 January 2005 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 J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6.5 hours from 8.30am to 3pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, menu, rotas, training, supervision, health and safety and fire records. The lunchtime meal and interactions between staff and residents were observed. Twelve residents, the majority of staff and two professional visitors were spoken with. The homes manager was not present during this inspection. Discussions took place with the homes training officer, who was in charge at the time of this inspection. 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’. A service user guide had been provided to each resident to give him or her information about 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, and the staff action required to ensure these needs were met. A system for the safe storage and administration of residents’ medication was in place. A care worker had been identified as having responsibility for organising activities, and all residents said they enjoyed the activities provided. 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. It was well decorated, in the main. 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. Sufficient bathing facilities were provided to ensure residents personal care needs were met. The central laundry and kitchen were well equipped to meet residents’ needs. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 6 Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. 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. What has improved since the last inspection? What they could do better: The care plans required auditing to ensure they contained up to date and relevant information on all aspects of health, social and personal care needs to ensure residents needs were addressed and met. Written agreements and risk assessments had not been undertaken for residents that self-administered medication, to promote safe practices. Sufficient cutlery had not been provided to one resident to help them eat their meal. Lounge carpets in both units were stained, some bedrooms had slight damage to the decoration. One bathroom was used to store two large easy chairs. Staff files did not contain all of the information required to ensure safe recruitment procedures were adhered to. Whilst the home had re-organised the procedures for staff supervision, these were not taking place at the required frequency to ensure staff had appropriate support. Some staff required refresher training with aspects of mandatory training, including food hygiene, first aid, moving and handling and fire instruction. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 7 Some residents were moved in wheelchairs without footplates in use. Written risk assessments to evidence that this was in response to identified need had not been undertaken. Several air fresheners and cleaning sprays, belonging to a resident, were insecurely stored in one lounge, potentially compromising the safety of residents. 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 J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 9 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 standard(s) 1,2,3 and 5. Standard 6 does not apply to this home. A service user guide was available, which provided information about the home to residents. 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 relatives to make informed choices. The information available and actions taken ensured that standards were met. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 10 EVIDENCE: Each resident had been a copy of the homes service user guide, to give them information about all aspects of the homes procedures, environment and staff. These were kept in residents’ bedrooms. Statements of terms and conditions were undertaken with residents to ensure that they were provided with information about their rights. 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. 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 J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 11 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 standard(s) 7,8,9,10 and 11. Each resident had a care plan, to ensure his or her opinions had been sought and needs assessed. These required some updating to ensure all aspects of identified needs had been addressed and were consistent with care practices. Health care needs were monitored and met. Systems were in place to ensure the safe administration and storage of medicines. Residents’ privacy and dignity was respected. 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 had been reviewed on a monthly basis, some information was not included or up to date. One plan included information on a specific issue that had been identified for staff to monitor, however no further information relating to this issue was recorded. One plan contained information on the staff action required to meet an identified need, this conflicted with the care practice undertaken. One initial assessment referred to a specific issue that was not identified in the care plan, therefore not all identified needs were being addressed. One resident had not signed their care plan, and a further plan checked was only signed in one section. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 12 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 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. Medication was stored securely and Medication Administration records were up to date. The inspector observed part of a medication administration round and staff undertook this safely. 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. Whilst care plans made reference to residents wishes regarding dying and death, these only stated `not discussed’, or `no plans as yet’. The plan did not specify why this was the case, or whether this had been the decision of the resident. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. Residents were able to make choices about how they spent their time. A range of activities were offered to residents, to improve choices and maintain interests. 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 said they were able to get up and go to bed when they chose, and were seen using different areas of the home according to their preferences, if able. A member of care staff had been identified as responsible for organising activities, to provide a range of appropriate social opportunities. Residents were free to join in any organised activities. All of the residents said they enjoyed the range of activities offered, and said enough were provided. One resident said that they were looking forward to a trip to the seaside, which had been organised. Activities organised in the home included ball games, card games memory games, manicures and pedicures and exercise. One resident said that they really enjoyed the manicures, because they made them really happy. Residents confirmed that they were able to see their visitors in private, and their family could visit at any time. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 14 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. 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. One resident chose not to eat their mid-day meal in the dining room and staff respected this. However, they had not been provided with sufficient cutlery to eat their meal in comfort, and as staff were busy in the dining room this had not been identified, so the resident experienced difficulty as their needs had not been met. Staff must be vigilant and ensure residents are provided with all of the equipment needed to meet needs, as some residents would be unable to vocalise any difficulties experienced. Bedrooms contained a range of personal possessions, enabling residents to make their room comfortable and homely. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. The homes complaints record was unavailable for inspection. 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 J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,20,21,22,23,24,25 and 26. The home was clean and generally well maintained. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and bedrooms were well decorated and personalised. 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. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 17 Some bedrooms had slight damage to the decoration, and all of the lounge carpets seen were stained and required cleaning to eradicate marks, or replacing, in order that the environment was maintained. 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 was used to store two large easy chairs, restricting access to facilities. 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 J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Agreed levels of staff were being maintained. 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. Staff undertook periodic training to keep them up to date. A staff training plan and individual training records were maintained. EVIDENCE: The rota indicated that agreed levels of staff were being maintained to meet the needs of residents. Residents felt that enough staff were provided. Recruitment to care staff vacancies was taking place. Agency staff covered any gaps in the rota, 4 shifts in the month previous to this inspection were covered by agency. Of the 35 care staff, 6 staff had achieved NVQ level 2 in care, a further 5 staff were being registered to undertake the training. This did not meet the recommended 50 of the care staff trained to NVQ level 2 in care by 2005. Whilst staff files contained the majority of information required to ensure safe practices undertaken, two files checked did not contain proof of identity or a photograph. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 19 A training policy was in place to ensure staff undertook appropriate training to develop their skills and meet the needs of residents. A training co-ordinator was employed at the home. Staff undertook induction and foundation training to ensure they had the skills needed to efficiently carry out their duties. Individual training records were maintained to enable these to be monitored and appropriate training provided. Residents said that the staff were good at their jobs. The interactions observed evidenced that staff undertook their duties competently. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36,37 and 38. A quality assurance system was in place, to seek the views of residents and their representatives. 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, hazardous substances belonging to a resident were insecurely stored in one lounge, some residents were moved in wheelchairs without footplates in use, all posing potential hazards to the safety of residents. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 21 EVIDENCE: Surveys with residents and/or their families and their relatives were undertaken, to obtain their views and inform practice. Staff supervision, to develop, inform and support staff did not take place at the required frequency of six times each year. However, the manager was in the process of reorganising the procedures for staff supervision to address this issue. Regular staff meetings took place, to update staff and inform care practices. 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. The fire service had inspected the home and any recommendations made had been undertaken to ensure that home was safe. 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. Some mandatory training had taken place the week prior to this inspection. 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. Several residents were moved in wheelchairs without footplates in use. Care plans did not include a written risk assessment to identify that this practice was in response to identified needs. One plan contained information that conflicted with care practices regarding use of footplates, resulting in the residents needs not being met. Air fresheners and disinfectant, belonging to a resident was insecurely stored in one lounge, posing an avoidable risk to residents. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 3 x 2 3 1 St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 23 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 38 Regulation 13 Requirement An audit of staff fire instruction must take place and any identified training provided. A record of staff fire training must be forwarded to the CSCI. Residents must not be moved in wheelchairs without footplates in use unless a written risk assessment has been undertaken that identifie this is in the best interests of the resident. All substances which may be hazardous to health must be securely stored at all times. Care plans must contain full, relevant and up to date information on all aspects of health, social and personal care. Information recorded in care plans must be consistent with care practices. Where able, residents must sign care plans. Written risk assessments and signed agreements must be undertaken when residents selfadminister medication. Sufficient cutlery must be provided to residents to ensure they can eat meals without difficulty. J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc 2. 38 13 Timescale for action Within two weeks of the inspection date. Immediate 3. 4. 38 7 13 15 Immediate 1/09/05 5. 8 13 1/09/05 6. 15 12 1/09/05 St Catherines Nursing Home Version 1.30 Page 24 7. 19 23 8. 19 23 9. 10. 11. 12. 21 29 36 38 23 18 18 13 All rooms with damaged or stained decoration must be redecorated. (Previous timescale of 1/05/05 not met). All damaged and stained caarpets must be cleaned or replaced. (Previous timescale of 1/05/05 not met) Bathrooms must not be used as storage. Staff files must contain proof of identity and a photograph. Staff must receive formal supervision at the required frequency of 6 times each year. An Audit of staff mandatory training must be undertaken. Any identified gaps in training must be provided. All staff must have up to date training in Moving and handling and Food Hygeine. 1/09/05 1/09/05 1/09/05 1/09/05 1/09/05 1/09/05 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 28 Good Practice Recommendations 50 of the staff team must be trained to NVQ level 2 in care by 2005. St Catherines Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 © 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 Nursing Home J55 S21809 St Catherines V230015 14.06.05 UI Stage 4.doc Version 1.30 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!