Inspection on 17/09/07 for St Catherines Residential Care Home

This inspection was carried out on 17th September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Catherines Residential Care... 25/09/06

St Catherines Residential Care... 06/01/06

St Catherines Residential Care... 28/06/05

St Catherines Residential Care... 29/09/04

St Catherines Residential Care... 05/05/04

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Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Catherines Residential Care Home 61 St Catherines Lincoln Lincs LN5 8LR Lead Inspector Doug Tunmore Unannounced Inspection 17th September 2007 10:00 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 Residential Care Home DS0000002420.V346216.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 Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherines Residential Care Home Address 61 St Catherines Lincoln Lincs LN5 8LR 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) 01522 520643 mark@stcatherines61.wanadoo.co.uk St Catherine`s Care Homes Limited Mr Mark James Browne Care Home 14 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (14) of places St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Old Age, not falling within any other category (OP) - 14 Dementia - Over 65 years of age DE (E) - 5 The maximum number of beds registered is 14 2. Date of last inspection 25th September 2006 Brief Description of the Service: St Catherines cares for older people in a non-smoking environment in two detached properties situated on the main Lincoln to Newark road, the town centre of Lincoln is a short bus ride away. The main house provides accommodation for ten residents; the smaller property provides accommodation for four. There is a third property within the grounds, this is not registered with the Commission and is only used for private meetings, staff training and hairdressing. There are two small gardens and a car parking area. Both houses have two floors and there is a stair lift to the bedrooms on the first floor in the main house. There are a variety of aids and adaptations in the main building to allow residents to move around the home more independently. Eight of the bedrooms are single; one double room has en-suite facilities. There are five communal toilets, four communal bathrooms and three shower rooms. Mr Mark Browne is the Company Director of St Catherine’s and also the Registered Manager. Since the previous inspection the home has varied its registration to include up to five beds for dementia care. The fees at the inspection visit on the 17/09/2007 ranged from £348:00 to £431:00 each week. Extras are for hairdressing which range from £3:50 upwards, chiropody £5:00, toiletries, personal newspapers and magazines. The provider also makes a charge of £5:35 per hour for escorting residents to hospital. Information about the home can be obtained from the manager of the home. The service user’s guide and the homes terms of condition relating to the stay of residents at this home is given to residents prior to admission. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by the Commission for Social Care Inspection (commission) including the homes previous inspection reports, their service history and the homes Annual Quality Assurance Assessment form hereafter in this report referred to as AQAA. No surveys were sent to the home by the commission in time for this inspection. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The inspector spoke with two of the people who were being case tracked and joined three other people for lunch. The inspector also spent time with the provider/manager the deputy manager and two carers. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? What they could do better: St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 6 The manager needs to introduce body maps so as to chart falls and bruises/cuts as a result to residents so as to show any increase of incidents at a glance. The providers complaints form needs to be changed so as to provide a place for complainants to sign regarding the outcome of any complaint that they have made. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted into the home only after a full needs assessment has been carried out, either by the home and/or health care or social care agencies. Residents are encouraged to visit the home prior to admission to see if they like it. EVIDENCE: A review of all information available prior to this inspection including a previous visit report dated September 06 and evidence seen at this visit in residents files showed that the home does not admit residents without a care needs assessment being undertaken. The deputy manager evidenced that prospective residents are written to by the home confirming that they can meet the residents care needs or not. Residents St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 9 files showed that those residents who were being case tracked had contracts setting out the terms and conditions of their stay. The providers AQAA evidences that ‘we always carryout assessments with social workers, families and medical teams’. Our prospective residents are invited to spend a day or a few days with us in order for them to see if they would like to make this home their home’. Both residents who were being case tracked confirmed that they had their care needs assessed by the deputy manager and had visited the home prior to admission ‘to see if they liked it. One stated that I had been here three or four months to make my mind up’. The provider does not undertake intermediate care. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and welfare needs of people living in the home are fully met. Medication is safely administered. Care plans address the intimate care needs of residents and their wishes regarding their privacy and dignity. EVIDENCE: A previous visit undertaken in September 06 found that evaluations of both care plans and risk assessments must be improved to include details of any changes required to the current care given. We saw at this visit that resident’s files had been updated and had been signed by those people who were being case tracked. Care needs admission assessments, and evaluations were seen to be of a good standard containing all the information required to direct those who care for these residents. We looked at care plans which established the intimate care needs of residents and what help they require when bathing or toileting or how their privacy and dignity can be maintained. Carers were able to demonstrate how to deliver personal care to residents in a sensitive manner. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 11 Those residents being case tracked stated that they had signed their care plans. They also commented that cares ‘are vary good with us and help with everything’. The carers come straight away when we press the buzzer’. The AQAA shows ‘that care plans are reviewed monthly or as required. Risk assessments are also updated as required. Residents are treated with privacy and dignity at all times. All personal care is conducted with full privacy and dignity’. The care plans of residents showed that GPs, community nurses and chiropodists visit the home on a regular basis to attend to their health care needs. The pharmacist visited the home in 2007 and recorded that medication evaluation carried out and stick control very good. The senior carer confirmed that she had safe administration of medication training six months ago. She was also seen administering medication to residents using pots and disposable gloves and coaxing residents in a friendly manner to take their medication. Medication sheets were examined and it was found that an accurate record is kept of all medication given to residents on the day of this visit. Three residents stated that they do not self medicate and that carers give them medication when it is time. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make relatives and friends of residents welcome in this home. A range of activities are made available to residents which they have a choice to participate or not. Choices of meals are made available at this home, which are discussed with residents. EVIDENCE: A previous visit to the home found that individual social preferences are recorded within care plans and records are kept of activities and trips out. Recent events had included entertainers, a fish and chip supper and a ‘war time sing-a-long’. Residents confirmed during this visit that ‘we do activities such as bingo and cards, visited a local pub for an evening meal and attended a Christmas party at another pub. Another residents stated that ‘I can stop up and watch my television in my room as long as I like, ‘the carers bring me tea and biscuits’. The AQAA stated that we invite family and friends to join in all activities, visitors can on occasion have meals with the relatives. We St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 13 always ask our residents before arranging any activities inside or outside the home to gain different preferences. Diets are discussed and catered for on admission and any allergies noted. Care records identify residents’ likes and dislikes and any health requirements. On this visit the inspector joined residents for lunch and found the meal provided to be hot and delicious. Residents made complimentary remarks about the food ‘its always served hot’, ‘ there’s always plenty of it’ and we have a variety of choices’. Tables were nicely laid with tablecloths/napkins and condiments. Residents living in the small house are quite independent and are able to make their own drinks and they have the facilities to cook if required. The main meal of the day is prepared and cooked in the main house and residents said that they are always hot when they receive them. No visitors were seen on the day of this visit but people said that their visitors are always made welcome and are offered tea or coffee. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures for addressing and monitoring complaints and concerns are in place and residents are aware of how to make a complaint. Residents feel safe and confident in approaching care staff regarding any concerns that they might have. EVIDENCE: All residents are given the service users guide, which contains the homes complaint procedures. The home has a detailed complaints procedure. The providers AQAA states that we have an accessible complaints procedure that all residents, supporters, families and staff are aware of. This is placed around the home. We have not had any complaints in the last twelve months. People commented that ‘we have no complaints there is nothing to complain about’. Other verbal comments were we feel safe here there are always staff around. We looked at the complaints form, which did not have a place for people to sign or comment about how their complaint had been handled. The deputy manager commented that this form would be amended for people to sign the complaint off when completed. The manager commented that protecting vulnerable adults training was undertaken in 2006. Two carers stated that if they became aware of an abusive situation they would report it to the manager or the commission. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well-decorated, homely and safe accommodation. Any maintenance is promptly addressed. EVIDENCE: Past visits have found the interior and exterior decoration is well maintained and improvements to the home included a new kitchen, repainting the outside of the building and the redecoration of one bedroom. This visit found that six bedrooms and the lounge had been decorated and a new chair lift and carpeting is to be fitted in the near future. An inspection of the home found it to be clean and tidy with a pleasant smell throughout. Colours, pictures and signs are being used to help residents with dementia to find their way around the home. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 16 The grounds are very small but well kept with a patio being built for the residents. Two bedrooms were viewed and these were personalised with resident’s memorabilia. One resident was visited in her room and stated that she likes her room and has bought her own things with her. Three double rooms were also seen which used screening around the sink that ensured their privacy and dignity when washing. We looked at people’s files, which contained adequate risk assessments relating to those risk to individual residents in the homes environment and their wheelchairs. St Catherines Residential Care Home DS0000002420.V346216.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is staffed with carers who were experienced, competent and educated to care for older people. Residents are protected by robust recruitment practices. EVIDENCE: The providers AQAA shows that all but two carers have a nationally recognised qualification in caring for elderly people. It also evidences that all new staff are thoroughly checked and do the induction process before being able to work unattended. This visit found that records of staff employed by the provider had been recruited using robust procedures. Carers stated that they have undertaken all checks and have done induction training. A previous visit made in 2006 found that a system had been put in place to monitor dependency levels of residents living in the home and the staff rota showed that there were enough staff on duty to meet the current needs of residents and staff and residents spoken to confirmed this. The deputy manager confirmed that all carers are given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 18 The homes training plan was seen and found to be up to date. The training record identified those workers who had undertaken training in 2007. Two carers stated that she has a qualification in caring for the elderly and is going on to gain further qualifications. They also confirmed that they have undertaken fire training, infection control, caring for residents with dementia, moving and handling and food hygiene. Evidence was also seen that further courses are being arranged through learn direct at Lincoln College. One carer stated that ‘she loves it here its great and we spend time with residents in the lounge’. Residents commented that ‘staff are always around, they come quickly when I press my buzzer’. St Catherines Residential Care Home DS0000002420.V346216.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well lead by a competent and committed manager. This had resulted in a confident, supported and trained staff team. Records show that residents’ health and general welfare and safety are promoted. The home ensures that the residents have the opportunity to voice their views and opinions. EVIDENCE: The provider is also the registered manager, he is supported by a deputy manager and both have completed the Registered Managers Award and NVQ level 4 in Management. Residents and a carer commented that the owner and the deputy manager are very nice and are approachable and supportive’. A carer stated that the deputy manager is brilliant, if you have any worries she St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 20 will always listen to you’. Other comments were that the manager and deputy manager help us with our training if we have a problem. The providers AQAA evidences that, feedback is sought from residents through questionnaires. Views of families, friends and outside organisations are also obtained. The provider’s surveys were seen and recorded very positive responses in respect to the care provided to residents. These responses now need to be published on the resident’s notice board for the information of all residents. All risk assessments are carried out to promote safe working practices. Residents meetings are held and residents spoken to said they feel comfortable to raise matters at them. Residents’ finances held by the home were checked and found to be in order. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. The AQAA evidenced that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training and as a regular training event. All files were seen to be kept safe and together for the information of all workers. The providers AQAA also evidenced that maintenance and service histories of all aids and adaptations are carried out as required by law. St Catherines Residential Care Home DS0000002420.V346216.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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catherines Residential Care Home DS0000002420.V346216.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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