CARE HOMES FOR OLDER PEOPLE
St Catherines Residential Home 19-21 St Catherines Road Bitterne Park Southampton Hampshire SO15 2PA Lead Inspector
Lorraine Parton Unannounced Inspection 6th January 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 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.V259702.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th October 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 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.V259702.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The second inspection of the inspection year took place over 5 hours and the purpose was to ensure compliance with previous legal requirements brought to the homes attention at the first inspection in October 2005 and to complete the inspection process for the year. The inspector audited 8 standards and reassessed 4 standards, in which the inspector had raised requirements at the last inspection. All key standards have now been assessed throughout the year. It is recommended that the reader of this report reads the last inspection report for October 05, to ensure that a total overview of the home is obtained. The inspection involved a walk around the home and an audit of some of the homes documentation. The registered providers assisted the inspector throughout the inspection. Much of the inspection was spent talking to the service users who displayed their involvement in the home. Service users spoken to advised the inspector that they enjoy living at the home and several service users stated “it could not be any better”, “I love living here” and that the homes staff are ‘lovely’, one service user stated that they have a high regard for the staff working in the home. What the service does well:
The home provides a homely and welcoming environment that enables service users to access all areas of the home and garden. All service user rooms are personalised and service users are encouraged to have their own personal possessions in their rooms. Service users spoken to stated that the homes staff provide an excellent service. The inspector witnessed staff interactions with service users and noted the obvious good relationships that were in place. Service users stated that the care that they received is excellent, which is supported by care plans and clear records that are being maintained on a regular basis. A requirement has been made for the home to review all service user plans to ensure relevant information is included in the plans. All service users spoken to advised the inspector that the home provides a good choice of meals and that the quality of the meals are good. Service users stated that the home offers a variety of choices and that they are asked what
St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 6 meals they would like. This standard was assessed at the last inspection and was met. Staff spoken to displayed a commitment to providing a high standard of care and support to the service users living at the home. All staff displayed an understanding of service user needs. What has improved since the last inspection? What they could do better:
The home must consult with their fire officer to ensure that the controls that have been implemented to protect service users who wander, is within current fire regulations. The home seeks the views of service users and some visitors to the home, however, this is not formalised to ensure views of all stakeholders of the business are taken into account. The home is required to review all the homes systems to ensure that service user views about the service they receive and their views about for example activities, meals and participation in the home is taken into account and incorporated into the homes policies and procedures. The home, whilst starting staff supervisions, these were found to be inadequate. The home is required to ensure all staff are offered formal supervision at least six times per year. The home has implemented a range of risk controls for areas, such has fire, hot water, hot surfaces, safe use and storage of chemicals, legionnaires and falls etc. On audit of the homes risk assessments some of these were found to be inadequate and for some areas of risk had not been assessed or documented. A requirement has been made. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 7 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.V259702.R01.S.doc Version 5.1 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 Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 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): None EVIDENCE: None of the standards were assessed on this occasion. The previous inspection in October 2005, identified that standards 3,5,6 were fully met. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Some service user plans need developing. Medication practices are safe. EVIDENCE: The inspector audited two service user plans, which were found to include basic information and risk assessments. Service user information was kept in several areas and did not always cover all appropriate areas. Following discussions with the homes manager it was agreed that service user plans would be reviewed and developed where necessary to ensure all the required information needed to meet needs is included in the plans. Some service user plans had not been signed by either the service user or their representative and one new service user plan needed enhancing. A requirement has been made. The home has a medication policy and procedures in place. The home operates a monitored dosage system that is supplied by the local pharmacist, who makes monitoring visits to the home on a monthly basis.
St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 11 The home operates within a medication policy. The home keeps a record of medication received, administered and returned to pharmacy. The home operates a monitored dosage system provided by a pharmacist who visits the home on a regular basis. Only staff who are trained in the safe handling of medication give medication. On audit of the homes medication and records they were found to be satisfactory. Through discussions with staff they displayed their awareness of service users medication and side effects totally. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: None of the standards were assessed on this occasion. The previous inspection in October 2005, identified that standards 12,13,114,15 were fully met. The inspector spoke to several service users throughout the inspection who all stated that they enjoyed living in their home and that the home continues to provide a range of activities in which they enjoy. Several service users go out on a regular basis supported by the homes staff, including their clubs, shopping, meals out and visiting church groups. All service users spoke positively about the Christmas festivities and stated that the carol service and the party held in the home were excellent. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: None of the standards were assessed on this occasion. The previous inspection in October 2005, identified that standards 16,18 were fully met. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: None of the standards were assessed on this occasion. The previous inspection in October 2005, identified that standards 19,23,24,25,26 were fully met. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 15 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): 27,28,29,30 The home had adequate staff on duty, who were found to be well trained and competent to do their jobs. The home has suitable recruitment procedures in place for the employment of new staff. EVIDENCE: Three staff were on duty at the time of the inspection. Staff confirmed that the home is covered by three carers during the day. The inspector had access to the homes rota, which also confirmed the above. The registered manager and one of the homes staff are currently undertaking the NVQ 4 training and the home has planned that 2 carers are to undertake the NVQ 2 within the next month. Service users confirmed that they felt safe in the home and that the homes staff are always supportive and professional in their approach. The home has policies and procedures in place to protect vulnerable adults. On speaking staff they displayed their awareness and understanding of the homes policies on reporting any issues that may be abuse and how to maintain privacy and the dignity of the service users living at the home. Staff displayed an excellent awareness of service user needs. Staff confirmed that they receive regular training and that they had received training since the last inspection.
St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 16 One new member of staff advised the inspector that they had received an induction into the home, which included one to one training with the manager and senior staff on moving and handling, medication, fire and care practices. The home also ensured the new employee shadowed a senior carer for a minimum of two weeks before working alone. Two staff files were audited by the inspector and found to contain all the relevant information. This included references and CRB and POVA checks. Staff training records were maintained and included training courses in moving and handling, health and safety, dementia care, depression and mental health, fire and first aid. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 The home is well run and has an ethos of a family environment. Service users are consulted about the running of the home, however, this needs formalising. Adequate financial procedures are in place. The home needs to implement a system for staff supervision. Service users are protected by the homes health and safety policies and procedures. EVIDENCE: Staff and service users spoke positively about the homes manager. Service users confirmed that the manager is available most days and that the manager
St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 18 seeks their views about any changes to the home. The manager is currently completing the NVQ 4. The registered manager also is one of the providers and as such has responsibility for two other premises. Discussions were held with the providers regarding the future need to have registered managers of their homes. The home does occasionally hold service user meetings and on a daily basis service users are spoken with to see if there are any issues. The home has started to complete questionnaires and these are available for service users and visitors to the home. On audit of the completed questionnaires positive comments were found about the service received and the homes staff. Service users spoken to confirmed that their views are listened to and that the home acts on their concerns. Following discussions with the proprietors, the home does not document the service users meetings and it is recommended that the home formalises their monitoring of the quality of the service it provides. The home does not manage any service users finances and has a system in which they invoice families or representatives for monies spent in the home. Individual records are being maintained and any charges for extras are explained within the contracts. Service users choose to have these extras and families and representatives have signed an agreement for the extras their relatives wish for. The home had started to implement staff supervisions but this was found to be in the early stages and not completed for the majority of staff. This remains outstanding from the last inspection and a further requirement has been made. The home has a range of risk assessments and policies and procedures for the home, staff and environment. The home has undertaken a risk assessment for the risk of service users wandering out of the home onto the nearby road, however, has not fully implemented any controls. The home is required to consult with their fire officer with regards to any controls that may be necessary to prevent service users who wander accessing or being at risk from the main road near the home. Some areas of risk had not been assessed and included in the health and safety procedures. A requirement has been made. All certificates were found up to date. St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X X X 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 3 2 X 3 2 X 2 St Catherines Residential Home DS0000011952.V259702.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13.3 Requirement Consult with the homes fire officer with regards to controls to protect service users who may wander out of the home. Provide a copy of their report to the CSCI. This remains outstanding from the last inspection. 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. This remains outstanding from the last inspection. Review and develop the homes current risk assessments and complete risk assessments for areas already not completed. Implement suitable controls for any identified risks. Review and develop all service user plans to ensure all care needs are incorporated into the plans. Implement staff supervisions and appraisals. Supervisions must be provided at least 6 times per
DS0000011952.V259702.R01.S.doc Timescale for action 31/03/06 2 OP33 24 31/03/06 3 OP38 13 31/03/06 4 OP7 7 31/03/06 5 OP36 18.2 31/03/06 St Catherines Residential Home Version 5.1 Page 21 year and documented. 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.V259702.R01.S.doc Version 5.1 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
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