Inspection on 23/05/06 for St Catherines Nursing Home

This inspection was carried out on 23rd May 2006.

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.

Other inspections for this house

St Catherines Nursing Home 27/04/10

St Catherines Nursing Home 11/04/08

St Catherines Nursing Home 18/04/07

St Catherines Nursing Home 10/01/06

St Catherines Nursing Home 14/06/05

St Catherines Nursing Home 11/01/05

St Catherines Nursing Home 12/05/04

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Snydale Care Home

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Whiteley House

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Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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

CARE HOMES FOR OLDER PEOPLE St Catherines Nursing Home 152 Burngreave Road Sheffield South Yorkshire S3 9DH Lead Inspector Mr Rob Curr Key Unannounced Inspection 23rd May 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherines Nursing Home DS0000021809.V295579.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 Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 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 None St Catherines Nursing Home 1996 Limited Post Vacant 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.V295579.R01.S.doc Version 5.2 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. 10th January 2006 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. Current fees range from £303 - £483. The current Service User Guide is being reviewed. This will further inform prospective service users of the facilities at the home. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The current provider has recently purchased this service. Therefore the registered providers were given 48 hours notice of this inspection taking place, to enable the relevant managers to be present. The site visit took place from 8:30 am to 4:00pm. The inspector carried out an inspection of a proportion of the environment. A selection of records were examined, including, care plans, residents finances, complaints, quality assurance, staff training, recruitment and supervision. The training co-ordinator completed a pre-inspection questionnaire. Two interviews were conducted with relatives, on behalf of the resident, to give the inspector information on aspects of the home. Eight service users were spoken with, two of whom were able to share their views on living at the home. Discussions with the homes area manager, training manager, and the majority of staff on duty took place. Interactions were observed between staff and residents. The new providers have proactively identified the majority of policies and procedures that need to be reviewed and actioned. These are referred to throughout this report. The inspector would like to thank the residents, their relatives, and the staff at the home for their openness and support of the inspection process. What the service does well: The new providers have circulated a ‘Quality Survey’ to residents and relatives. They have analysed the results of this survey. All of the comments made to the inspector were positive. Residents said the staff were ‘very helpful’ and ‘the home is under new management’. Relatives were happy with the care provided to their loved one and stated that they had good relationships with the staff at the home. One relative said the care provided was ‘very good’. The interactions observed and overheard between staff and residents appeared respectful and caring. Staff responded promptly to reassure anxious residents, and spent time chatting to and reassuring individuals. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 6 The statement of purpose and service user guide was in place, to provide information about the home to prospective and existing residents, although these documents were under review because the majority of the information relates to the previous providers aims and objectives. Relatives and staff confirmed that prospective residents had been able to look around the home and meet other residents and staff before choosing to move in. Systems were in place to ensure the safe storage and administration of medication. The interactions observed between staff and service users appeared respectful. Choices were offered and the routines at the home were flexible. Residents were free to walk around the home. Visitors were welcomed at any time. The visitors spoken with said they were ‘very happy’ with the care their relative received. The homes menu was varied, and choices were offered. Special dietary needs were catered for. The home had a complaints procedure, to ensure any complaint was taken seriously. Any complaints that had been made were handled well within the 28 days timescale outlined in the complaints procedure although the new complaints procedure needs to be circulated. Sufficient staff were provided to care for residents. Staff undertook periodic training to keep them up to date. Systems were in place to ensure the safe storage and administration of resident’s monies. All of the people spoken with said that the new providers had communicated clearly with them and there had been a number of meetings to answer any questions and attend to any concerns. What has improved since the last inspection? What they could do better: Full needs assessments were not always carried out prior to admission. This does not ensure identified needs can be met. Care plans were in place for all residents, but did not fully detail the staff action required to ensure all aspects of care were met. The staff spoken with were not clear about adult protection procedures. Requirements made at the last inspection in relation to care plans, recruitment procedures and staff training, have been carried forward as further improvement was required to meet these standards. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 7 Care staff worked hard to provide some activities, to improve choices and quality of life. However, these were limited. Residents would benefit from additional resources and activities suited to their individual need and interest. The new providers have inherited a number of recruitment issues. There were members of staff that did not have a current Criminal Records Bureau disclosure. Immediate action was required to resolve this. The recommended 50 of the care staff team qualified to National Vocational Qualifications (NVQ) Level 2 in Care had not been achieved. Staff supervision, to develop and support individuals, did not take place at the required frequency. Some mandatory staff training was out of date. Whilst a rolling programme of training was in place, some staff required dedicated adult protection training although Food Hygiene and Moving and Handling training had been undertaken. The new providers were clearly aware of the need to address the issues around décor and worn furniture. The inspector and the management team discussed at length, the need for the proprietors to undertake a thorough audit of the environment. 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.V295579.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 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 the following standard(s): 1,2,3,4 and 5. Standard 6 does not apply to this home. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. The statement of purpose and service user guide were under review. The ‘contract of care’ was also under review. Assessments of needs were not always undertaken prior to admission, to ensure all identified needs of the prospective resident could be met. Prospective residents and/or their representatives were able to visit the home prior to admission, to inform their choices. EVIDENCE: The area management team informed the inspector that the homes statement of purpose and service user guide and ‘contract of care’ was under review. Copies of the previous ones were on display in the entrance area of the home to enable visitors to read. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 10 One resident’s file checked did not contain a detailed needs assessment to ensure identified needs could be met. Copies of social workers full needs assessments were obtained, where available, to provide the home with all relevant information. Families had been involved in the assessment process. Prospective residents and their representatives were able to visit the home, have a look around, and meet other residents and staff before choosing to move in. Two relatives spoken with said that this was very helpful in deciding which was the right home for their loved one. One relative stated that the staff and management had been very welcoming and supportive, which helped in their decision. One representative said that his mother’s relative had lived in the home, and that she wished to live there also. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9, and 11 Quality in this outcome area was good adequate. This judgement has been made using available evidence, including a visit to the home. Each resident had a plan of care, to inform staff of the actions required to meet assessed need. Further detail was required to ensure all relevant information was recorded. Records did not evidence that residents’ health care was monitored, to maintain health. The recording and administration of medication was well managed, to promote residents safety. Interactions observed between residents and staff evidenced that resident’s privacy and dignity was respected. Written policies and procedures were in place regarding dying and death, to ensure residents and their relatives were supported sensitively. However, wishes regarding dying and death had not been sought or recorded, to ensure any specific requests were carried out. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three care plans were examined. The management team were about to introduce anew care plan format. Some sections of the care plans seen were comprehensive and contained detail of the staff action required to ensure needs were met, for example, methods of communication. Other sections of the plans examined contained insufficient detail to inform staff how to respond to specific behaviour. There were a number of residents (4) being care for in their bedrooms. On meeting these residents it was observed that they had not had the appropriate support in terms of general health care and person hygiene. There were no records made in relation to fluid intake or care given that morning. This was discussed and addressed by the nurse in charge. The plans contained records of health assessments, such as moving and handling and pressure sores, although one resident was using a reclining chair and needed frequent repositioning to maintain comfort and security. There was no specific assessment for this practice. Nutritional assessments were not undertaken. Residents and visitors said that health care needs were met. Not all care plans were reviewed regularly. Qualified staff administered medication. Part of a medication administration round was observed; medication appeared to be administered correctly and safely. Care plans contained information on contacts with health care professionals, such as general practitioners and specialist nurses. Medication was stored securely. Medication administration records were fully completed and up to date. The details recorded corresponded with the medication stored. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. Staff were seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Residents preferred form of address was respected. Staff were seen to treat service users respectfully. Staff promptly responded to residents that became anxious in a kindly, reassuring and patient manner. One relative said that staff were ‘always patient and caring’. A policy and procedure were in place regarding dying and death. Relatives spoken with confirmed that they were kept informed of their loved ones health. Discussions with the manager and staff evidenced that residents and their families were treated with dignity at this sensitive time. No records had been undertaken regarding residents’ wishes in relation to dying and death, to ensure these were carried out. St Catherines Nursing Home DS0000021809.V295579.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area was good, but further improvements in the activities programme are needed. This judgement has been made using available evidence, including a visit to the home. Some activities were provided to residents by care staff, to improve choice and quality of life. Further activities that reflect specific and individual needs would benefit residents. The routines at the home were flexible and service users were able to choose how to spend their time, in line with health and safety and assessed risk, to maintain and improve the quality of life. An open visiting policy was in operation, in order to develop and maintain good relationships with resident’s representatives. Contact with relatives and friends were supported. The homes menu was varied, and special diets were catered for, to meet residents’ needs and maintain health. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 14 EVIDENCE: Care staff provided some activities, but this was limited due to staff time and availability. In addition, staff reported that the majority of residents were unable, or chose not to, participate in planned group activities. Choices would be improved with the introduction of additional activities that were suitable to meet residents’ individual needs. Residents were seen to walk freely around the home. A visitor spoken with said ‘I am always made to feel welcome, and have no concerns at all about the care of my relative, I am very happy with the care provided’. Staff supported residents choices, and were overheard to offer individuals choice of breakfast. The homes menu was varied and choices were offered. One resident spoken with said the food was ‘lovely’. Staff sat with the residents that required assistance with eating, and this support was given patiently and respectfully. The cook was clearly aware of individual residents special dietary requirements. There were plentiful stocks of food, which staff had access to, to provide snacks and drinks during the evening and night, if required. The cook and her team had been awarded an ‘Excellent Standard of Food Hygiene’ by the local Food Standards Agency. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened and responded to. An adult protection procedure was in place. Staff were not fully aware of these procedures, to ensure residents safety was promoted. EVIDENCE: The complaints procedure was on display in a communal area of the home. However this procedure is under review due to inform residents and their representatives of the current providers approach to complaints. A record of complaints was kept. No complaints had been received since the last inspection. The staff spoken with were unclear about the procedures to undertake in regard to adult protection but clear about the homes complaints procedure. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 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 the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. The home was clean and generally well maintained, to provide a pleasant environment for residents. Controls of infection procedures were in place, to promote resident’s health and safety. EVIDENCE: A tour of the building identified that some areas of the home were in need of decoration. Some homely touches were provided to create a comfortable environment for the residents. A handy person was employed to help maintain the environment. A rolling programme of redecoration and replacement was not in place. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 17 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): 27,28,29 and 30. Quality in this outcome area was poor. This judgement has been made using available evidence, including a visit to the home. Sufficient staff were provided to meet the needs of residents. Some staff undertook NVQ training, to enhance their skills, however, required levels of NVQ trained staff had not been achieved. The recruitment policies and procedures were not followed consistently. These practices do not ensure that staff are suitable for the post. A range of training was provided to staff, to improve their skills and enable them to support residents effectively. EVIDENCE: The rota evidenced that agreed levels of staff were being maintained. One resident spoken with said that enough staff were provided. Two visitors spoken with said they were happy with the levels of staff. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 18 The home had recruitment systems in place to protect residents, however, the following issues were noted: • • • • Application forms had not been fully completed Full employment histories had not been provided Not all references were from previous employers Three (3) members of staff did not have a criminal record bureau disclosure. The new management team displayed genuine concern with regard to these issues and made a commitment to take immediate action. Five staff had achieved NVQ Level 2 or above in care. A number of care staff were due to commence the training. This did not meet the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Induction and ongoing training were provided to staff. The training co-ordinator had worked hard to improve training records and ensure appropriate training was available to staff. A training matrix and individual training records were maintained, to assist in monitoring the training provided. Whilst relevant training events had been organised, for example in dementia, understanding diabetes, further emphasis needs to be placed on dedicated Adult Protection training and managing challenging behaviour. This clearly did not meet the needs of residents. Every effort must be made to ensure staff attend the training organised to equip them with the skills needed to provide residents with a good quality of life. Discussions with the homes management, staff, one relative, and records examined, evidenced that some residents displayed challenging behaviour on occasions, yet only a minimum of staff had attended relevant training. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 and 38 Quality in this outcome area was good, however, improvements were needed in respect of staff supervision and fire prevention. This judgement has been made using available evidence, including a visit to the home. A Manager had been recruited, but was not in post. A quality assurance system was in operation, to obtain and act upon the views of residents and relatives. Systems were in place to ensure resident’s monies were safely managed. Staff supervision systems required improvement, to ensure service users interests were maintained by best practice. Appropriate policies and procedures were in place. Records were stored securely to protect confidentiality. Health and safety systems were, in the main, maintained, to ensure residents were safe. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 20 Some mandatory training was required to ensure staff skills remained up to date. Further staff required emergency first aid training to ensure a qualified person was on duty at all times. Fire escapes need to be kept clear at all times to ensure the safety of everyone in the building. EVIDENCE: All of the staff and visitors spoken with said that they were looking forward to the new manager starting. A recent quality survey had been undertaken with residents and/or their representatives to gauge the service provided and obtain views and suggestions for improvement. The results of surveys had been collated, but had not been shared with the participants. The surveys examined all made positive comments about the home as well as areas of improvement. Resident’s monies were stored securely. The inspector examined two finance records, the amounts kept tallied with the records held. Informal supervision took place on a daily basis. However, formal staff supervision, to support and enhance staff skills, did not take place at the required frequency. A range of policies and procedures were in place to promote good practice and ensure resident’s needs were met. Staff were not yet aware of all the homes policies. Records were securely stored. The equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Fire drill training took place on a regular basis. However, there was no clear system in place to monitor this and ensure all staff participated in drills at the required frequency. There were wheelchairs and other equipment stored in a corridor that was a designated fire exit. This was dealt with immediately. A training matrix had been developed. This evidenced that some staff required refresher training in food hygiene and infection control. A proportion of staff had undertaken training in first aid. Further staff required emergency first aid training to ensure a qualified person was on duty at all times. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 21 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 2 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 2 St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 22 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. 2. 3. 4. Standard OP1 OP1 OP2 OP3 Regulation Sch 1. Sch 4(2) 5 14 Requirement A Statement of purpose must be produced outlining all the elements within Schedule 1. A Service User Guide must be produced outlining all the elements within Standard 1.1 Each service users must have a contract/terms and conditions. Records of pre-admission assessments must be available and maintained alongside other relevant records. (Previous timescales of 01/09/05 and 31/03/06 not met.) Care plans must contain specific detail on the staff action required to ensure assessed needs are met. All sections of the care plans must be reviewed on a monthly basis. (Previous timescales of 31/03/06 not met.) Where able, residents must sign care plans. (Previous timescales of 01/09/05 and 31/03/06 not met.) Systems must be in place for service users who are in bed to be appropriately monitored and DS0000021809.V295579.R01.S.doc Timescale for action 24/08/06 24/08/06 21/09/06 24/08/06 5. OP7 15 27/07/06 6. OP7 15 27/07/06 7. OP8 12 23/05/06 St Catherines Nursing Home Version 5.2 Page 23 8. 9. OP8 OP11 12 12 10. OP16 22 11. OP19 23 12. OP19 23 13. OP19 23 14. OP19 23 15. 16. OP28 OP29 18,19 Sch 2(7) 17. OP29 Sch 2 receive the support and care they need. All service users must have their nutritional needs assessed. 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. (Previous timescales of 31/03/06 not met.) The complaints procedure must be reviewed and made available to service users and their representatives. All rooms with damaged or stained decoration must be redecorated. (Previous timescales of 01/05/05, 1/09/06 and 31/03/06 not met.) All damaged and stained carpets must be replaced. (Previous timescales of 01/05/05, 1/09/06 and 31/03/06 not met.) The homes manager and responsible individual must undertake a thorough audit of the environment. A programme of renewal and maintenance of the premises (with timescales) must be produced and sent to the local office of the CSCI for agreement. 50 of the staff team must be trained to NVQ Level 2 in Care The identified members of staff that had no CRB, POVA first, or references must not work unsupervised until all the required checks have been completed. Under no circumstances must staff be recruited prior to an appropriate CRB disclosure being DS0000021809.V295579.R01.S.doc 24/08/06 24/08/06 24/08/07 21/09/06 21/09/06 21/09/06 21/09/06 21/09/06 23/05/06 23/05/06 St Catherines Nursing Home Version 5.2 Page 24 18. 19. OP29 OP29 Sch 2 Sch 2 20. OP36 18 21. OP38 13 22. OP38 13 received. All recruitment procedures must be adhered to. Staff files must contain a photograph. (Previous timescales of 01/09/05 and 30/04/06 not met.) Staff must receive formal supervision at eh required frequency of 6 times a year. (Previous timescales of 01/09/05 and 31/03/06 not met.) Any identified gaps in training must be provided. All staff must have up-to-date training in Adult Protection and Managing Challenging Behaviour. Fire exits must be kept clear at all times. 23/05/06 27/07/06 27/07/06 24/08/06 23/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP12 OP33 Good Practice Recommendations The organisation should introduce the new care planning system. A dedicated activities co-ordinator should be recruited to meet the recreational needs of the service users. The results of the Quality survey that took place should be published and circulated to service users/representatives and other interested parties. St Catherines Nursing Home DS0000021809.V295579.R01.S.doc Version 5.2 Page 25 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 © 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 DS0000021809.V295579.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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!