Inspection on 26/10/05 for St Catherines Residential Home

This inspection was carried out on 26th October 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 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 Home 22/10/08

St Catherines Residential Home 07/11/06

St Catherines Residential Home 06/01/06

St Catherines Residential Home 11/03/05

St Catherines Residential Home 07/10/04

St Catherines Residential Home 24/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE St Catherines Residential Home 19-21 St Catherines Road Bitterne Park Southampton Hampshire SO15 2PA Lead Inspector :orraine Parton Unannounced Inspection 26th October 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 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 Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Catherines Residential Home Address 19-21 St Catherines Road Bitterne Park Southampton Hampshire SO15 2PA 023 8067 2626 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) Mr Zamir Afghan Mrs Parigul Afghan Mr Zamir Afghan Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14), Old age, not falling within any other category (14) St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th March 2005 Brief Description of the Service: St Catherine’s is a care home situated in Bitterne Park, Southampton. The home is registered for fourteen service users within the categories of older persons, mental health and dementia care. The home is registered to accommodate up to three people under the age of sixty-five who have a mental health needs. The home has a range of bedrooms situated over two floors. The home also consists of a lounge, dining area, kitchen. To the front of the property is a small car parking area and to the rear is a large nicely maintained garden. The home is situated close to local amenities and a short journey away from the main city of Southampton. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 5 hours. The inspector assessed twenty standards during the inspection, the remaining key standards will be assessed at the next inspection. The inspection involved a walk around the home, discussions with service users, a visitor and with the homes staff. All service users spoken to confirmed that they were happy living at the home and that the homes staff provide an excellent service and a high standard of personal care. The inspector was assisted by initially the homes staff and then on their arrival at the home, the proprietors. The home staff were found to be professional and helpful throughout the inspection. The inspection also involved an audit of some of the homes documentation relevant to the provision of care for the service users living at the home. The inspector received nine comment cards from service users and visitors to the home. Comments received in them were found to be positive about the services they or their relatives received, however, one comment card indicated that one service user can be disruptive to the home. This matter was looked at during the inspection and has been included in the report. What the service does well: What has improved since the last inspection? St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 6 The home has acted on the requirements brought to the homes attention at the last inspection. One requirement relating to service users finance was not assessed during the inspection and will be assessed at the next inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 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 Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5, 6 New service users are only admitted following an in depth assessment of their needs. The home offers prospective service users or their representatives an opportunity to visit the home prior to agreeing to move in. The home does not offer facilities for service users requiring intermediate care. EVIDENCE: The home has had a few new admissions and on audit of one new admission file it was found to contain an in depth assessment of needs undertaken by the home’s manager. The manager had spoken to the service user either in their home’s or hospital and had also ensured that family or carers views had been documented as part of the assessment. The home had also received an assessment from the service users care manager. Both assessments formed part of the service users care plan. The home has a visiting policy that affords prospective service users or their representatives to visit the home prior to agreeing to move in. The inspector St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 9 spoke to one new service user who confirmed that they and their family had visited the home and had been afforded the opportunity to have a meal in the home prior to agreeing to move in. The proprietor/registered manager advised the inspector that occasional they refuse service user applications based on not being able to meet specific service user needs and based on compatibility with service users already living in the home. The home does not provide facilities for service users requiring intermediate care. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 All service users have an extensive care plan. All service users health care needs have been assessed and where necessary have access to relevant health care professionals. Risk assessments for service users who wander have not been completed. Service users confirmed that the homes staff, treat them with dignity and that their privacy is respected at all times. EVIDENCE: The inspector audited four service user plans, which were found to contain relevant care planning information, health care professional involvement where necessary, occupational therapist assessments and guidance for moving and handling for service users requiring this assistance and records of monthly and 6 monthly reviews. One new service users file displayed that an assessment of needs had been undertaken, which had been incorporated into the service user plan. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 11 Care plans identify risks and development goals as well as stating how health and personal care needs should be met. Service users are encouraged to make choices and decisions with support being given to minimise risks whilst maximising independence. Currently one service user wanders and occasionally displays aggression for which care plans are in place, however, the home has not carried out a risk assessment for the risk of wandering out of the home and have not implemented suitable controls for the identifiable risks. A requirement has been made for the home to look at ways of controlling the risk to service users who may wander out of the home and onto the road. The home must consult with their fire office regarding the use of controls around the outside of the home. All service users are afforded access to relevant health care professionals and service users are registered with a general practitioner of their choice. The home has completed assessments for moving and handling following seeking advice from relevant health care professionals. These assessments have been incorporated into the service user plans. Recently one service user has required more assistance with regards to behaviour due to dementia and the home has appropriately referred him/her to their care manager for additional support and alternative accommodation. Service users spoken to confirmed that the homes staff, respect their views and the need for their privacy and dignity to be up held. Staff were seen by the inspector to knock on doors before entering and interacting with service users in an equal and respectful manner. Service users confirmed that they receive personal care in private and are able to receive treatments and consultations in their bedrooms in private. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users are supported in their chosen lifestyles and encouraged to make choices about their lives. Service users are supported in whom they choose to have contact with. All service users are supported if necessary with access to the community. Service users confirmed that the home provides excellent food of their choice. EVIDENCE: All service users choices in lifestyles and preferences in activities are clearly documented in service user plans. Service users spoken to advised the inspector that the home provides activities and facilities that meet their personal wishes. Service users confirmed that the homes staff ask them what they want and do their best to provide or support community access if needed. Some service users go out alone and access local facilities of their choice. This includes shopping and going for walks. Service users, who are unable to go out alone are supported by the staff. Service users confirmed that the homes staff, take them out and that they enjoy this facility. Service users confirmed that the home provides outside visits to the theatre and areas of local interest. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 13 The home offers a range of in house activities and this includes games, knitting, musical sessions. The home provides daily papers for service users who wish and in the home is a range of books and games. Service users who wish to participate in their own interests are supported by the home and this has included painting, gardening and helping around the home. Service users spoken to confirmed that the home supports their choices in involvement in the home. Service users who wish have personalised their rooms and some rooms contain service users own furniture and belongings. Service users confirm that they have access to television and music in their rooms if they wish. The home has a visiting policy, which affords and encourages visitors at any reasonable time. Service users confirmed that they are able to see visitors in private in their own rooms and elsewhere in the home if not in use by other service users. A visitor to the home confirmed that they were able to visit when they wished and that the homes staff always made them feel welcome. The visitor further added that in their opinion the home was ‘excellent’. Service users spoken to stated that the home provides good food and offers a choice of menu. Individual choices and needs in food are catered for and this includes likes, dietary needs and special requests. The inspector was present for the lunch time meal and was afforded the opportunity to join service users for a meal. The meal was found to be tasty, well presented and nutritious. Service users confirmed that meals are always good and that the home offers choices for all meals. Meal times were noted to be relaxed and service users who were being supported were not rushed and their dignity was maintained. The home keeps a record of meals eaten by service users and a menu was provided to the inspector. Menus display a well balanced and nutritious variation, which, the staff stated are based on service users likes and dislikes. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users are aware of how to make a complaint and to whom. The home has procedures and practices in place to protect where possible service users. EVIDENCE: All service users have a copy of the homes complaints procedure, which has been included in the homes statement of purpose. A copy of the homes complaints procedure was on display by the front door and is therefore accessible to all visitors to the home. Service users confirmed that they were aware of the complaints procedure and that the homes staff had gone through it with them. Service users advised the staff that they would speak to the homes manager or staff if they had any concerns and if unresolved would speak to their families or friends. Neither the home or the Commission for Social Care Inspection have received any complaints since the last inspection. A record of a complaint would be maintained if necessary. The home has a copy of Hampshire’s Adult Protection procedure and a whistle blowing policy. On speaking to staff they displayed their awareness of what constitutes abuse and the appropriate action to take if necessary. All staff have received training in adult protection issues. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 25, 26 The home is clean, safe and well maintained and provides a homely environment for service users. Service users who wish have personalised their bedrooms with their own belongings. EVIDENCE: The inspector undertook a walk around the home and identified no issues in the rooms that were entered. The home was found to be homely, clean and suitable for service users. All areas of the home are accessible to service users and the rear garden was found to be well maintained. One service user advised the inspector that they used to help in the garden and that some of the garden they had planted and looked after for several years. At the time of the inspection service users were seen to be helping around the home. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 16 All rooms seen were found to include service users own possessions and some rooms contained service users own furniture. The inspector noted that these rooms were homely and service users own choice. The home has a maintenance programme and repairs are carried out as and when necessary. All certificates and routine maintenance were in place and up to date. This provides a safe environment. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 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): 30 Staff are competent to undertake their jobs, however, training for staff needs developing. EVIDENCE: On speaking to staff, they displayed their awareness of their roles and the service users living in the home. Service users confirmed that the homes staff are excellent and that they are aware of their needs and wishes. The home provides training in adult protection, basic food hygiene, medication, fire, first aid and dementia awareness. One member of staff has completed a course in moving and handling trainer and therefore can ensure all staff are trained and supported in moving and handling within the home. The home ensures all new staff are inducted into the home. The home follows a TOPPS induction programme. NVQ 2 training for staff was discussed as the home has only two staff out of eleven trained to this level. The home has agreed to review all staff training and a requirement has been made. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 38 Service users are consulted about the running of the home, however, this needs formalising. The home has completed some risk assessments and implemented suitable controls, however, these need documenting. EVIDENCE: Staff, service users and visitors to the home all spoke positively about the homes manager and staff. Service users confirmed that the manager is available in the home almost every day and that the manager seeks their views about the service they receive. The home does hold service user meetings and these are documented. Subjects discussed include meals and activities provided by the home. The home completes questionnaires for service users on a yearly basis and questions include staffing, privacy and dignity, meals and decoration of the home. The home has several thank you letters from relatives and service users, which on reading showed very positive St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 19 comments including ‘wonderful care’, ‘the home provides a loving atmosphere’ and ‘the staff are extremely kind’. Currently the home is not seeking the views of other stakeholders of the business and on discussion this was agreed by the manager to be undertaken. A requirement has been made. The home has undertaken some risk assessments and implemented controls for identifiable risks for example radiator covers, safe keeping of chemicals and thermostatic valves to baths to prevent scalding. The home has no documented staff risk assessments and the inspector gave advice on how this could be completed. Currently the home accommodates service users who may wander due to their dementia, which may pose a risk to their safety. The home has completed an assessment and incorporated this into the service user plans, however, no risk assessment has been completed and the home has not implemented suitable controls to ensure service users do not wander on to the nearby road. Following discussions the home is required to consider the access areas into and out of the home and garden. The home must consult with the fire officer with regards to the use of gates at the sides of the home. The home has agreed to document its risk assessments which will be assessed at the next inspection. The home should consider for example the risks of the environment, specific staff roles and the equipment used in the home. The inspector did not look at service user money, which had been a previous legal requirement. This will be assessed at the next inspection. St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13.3 Requirement Implement suitable controls in the home to protect service users who may wander out onto a nearby road. Consult with the homes fire safety office with regards to controls to protect service users who may wander out of the home such as side gates. Implement suitable staff training. This must include NVQ 2 training. Formalise a system to monitor the quality of the service the home provides. This must include a method of seeking the views of all stakeholders of the business. Timescale for action 31/01/06 2 OP38 13.3 31/01/06 3 4 OP30 OP33 18.1 (c) 24 31/12/05 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catherines Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Residential Home DS0000011952.V255344.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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