Inspection on 07/11/06 for St Catherines Residential Home

This inspection was carried out on 7th November 2006.

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 Home 22/10/08

St Catherines Residential Home 06/01/06

St Catherines Residential Home 26/10/05

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 Mr Richard Slimm Key Unannounced Inspection 7th November 2006 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 Home DS0000011952.V311824.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 Home DS0000011952.V311824.R01.S.doc Version 5.2 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.V311824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 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 has a condition of registration, agreed with the Commission to accommodate up to three people under the age of sixty-five who have mental health needs. The home is a large detached Victorian house that has a range of bedrooms situated over two floors; eight of the fourteen beds are situated within shared bedrooms. This constitutes over 50 of bed space, and may lead to a restriction in choice for service users wishing to be accommodated in single bedrooms. The home also consists of a lounge, dining area, small laundry area and a domestic style kitchen. There are three communal bath/shower rooms with WC facilities, and additional communal WCs. No bedrooms offer en suite facilities, but commodes are made available to residents with mobility problems during the night. To the front of the property is a small off road 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 centre of Southampton. The home is one of three residential care homes; one offering nursing care, owned and run by the registered persons within the county of Hampshire. The fees range from £387.00 to £550.00 per week. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site inspection visit to the home took place between the hours of 10.30 and 17.00 hrs on the 7th November 2006. This site visit was the culmination of pre-field work inspection activities including – • • • • • • A full review of the history of the service since the last inspection Gathering information from a variety of professional sources, including The Commission’s database Pre-inspection information provided by the home Contacts with and feedback from families and other external stakeholders Linking with CSCI staff who have knowledge/visited the service This was a key inspection, being part of a new inspection programme, called “Inspecting For Better Lives “ which measures the service against the core and/or key national minimum standards, and focuses on quality outcomes of people using the service. One regulation inspector carried out the visit, Richard Slimm. While in the home the inspector was able to meet 90 of the residents currently accommodated, carrying out case tracking with a number of service users. Additional paper work where necessary was reviewed, a tour of the premises took place, and the registered manager, assistant manager; staff members, visiting professional, relatives, residents’ friends and residents were interviewed. What the service does well: The home provides a small friendly care service for older persons who may be suffering from age related mental health problems. Residents have been encouraged and supported to personalise their bedrooms. Service users have access to all communal facilities of their home, with support when needed. Residents interviewed stated that they were very happy living at the home, and spoke highly of the staff team that support them. Residents had also developed meaningful friendships amongst themselves over the years. Ninety percent of the service user group were spoken to and they all confirmed that the quality of food was very good. A comment card from the local GP surgery confirmed that the home provides a good quality of care and support to their patients. This was also confirmed by a visiting GP verbally. Three comment cards were received from relatives/friends of residents and all confirmed that the home provides a good service to their St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 6 friends/loved ones accommodated at St Catherine’s. Four service user comment cards were returned before the site visit, and each was positive about the quality of service being provided. Staff members on duty were able to demonstrate a good understanding of the needs and wishes of residents, were seen to interact in positive ways with residents, and were committed to providing the best possible care and support to the resident group. The registered manager is a qualified/registered social worker, who is currently involved in gaining the registered managers award at a local college, with his assistant manager. What has improved since the last inspection? What they could do better: The home needs to improve record maintenance in the area of staff recruitment and selection checks. The records must include a clear audit trail of criminal records (CRB) and Protection Of Vulnerable Adult (POVA) checks, including the date checks are undertaken, the dates clearances are received, the outcome/results of the checks, the CRB/POVA reference numbers and the date when they need to be re-checked. The home needs to ensure they take up adequate references on all staff. Accepting testimonials without references is not acceptable practice. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 7 The home needs to ensure that medical administration record sheets (MAR sheets) are not changed of altered by staff involved in the administration of medications. The prescribing doctor who will instruct the pharmacist to produce administration guidance on the MAR sheet or the medication container must only alter these records. The home needs to provide the commission with written evidence of the action they are taking to ensure that at least 50 of the staff team are trained to the minimum standard of NVQ level 2. The owners may wish to look into ways of reconfiguring the accommodation at the home to increase the number of single bedrooms for residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherines Residential Home DS0000011952.V311824.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 Residential Home DS0000011952.V311824.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): 3 No service user moves into the home without having had his/her needs assessed and been assured that these will be met. New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not provide intermediate care services. Consequently key standard six was not assessed. Case tracking confirmed that service users are assessed prior to admission. Residents who are funded by local authorities are assessed by social workers/care managers and care plans drawn up with the home. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 10 Assessments cover all aspects of daily living and also cover any issues around mental health if relevant. Three service users confirmed that they were aware of their care records that were maintained at the home by staff. Staff members spoken to were able to demonstrate an awareness of the needs of residents. Residents confirmed their needs are met at their home. The home has an admission procedure, and provides prospective residents with information about the home. St Catherines Residential Home DS0000011952.V311824.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): 7-8-9-10 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. However, there was one concern with regard to one medication administration record sheet. Service users feel they are treated with respect and their right to privacy is upheld. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information gained via assessment is used to inform care plans for residents. These, wherever possible are shared with service users. Where service users St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 12 are very frail their relatives or friends are asked to sign these documents to agree the content. The current formats for care planning are somewhat dated and could be further developed in line with current thinking/best practice around more person centred approaches to planning care and support. However, it should be noted that staff members were aware of residents’ wishes as well as their needs, and service users spoken to confirmed this. A local GP confirmed verbally that she was happy with the quality of care and support provided to her patients at the home, and a comment card returned by the local GP surgery also corroborated this. Residents confirmed that they could see their GP on request and in private. The home makes arrangements to assess and monitor residents’ health care, and ensures residents health care needs are met. Residents’ social care needs are also identified and support put in place to support and/or meet these needs also. The degree to which more able residents are encouraged to maintain independence with their medications was unclear. However, at the time of the visit no residents were actively seeking to self-medicate. There was evidence that staff members listen to the wishes of residents’ in this area, but sadly this had led, in one instance, to staff amending MAR sheets without evidence and an audit rail that the prescribing doctor had been consulted and agreed the changes. The regulatory Inspector was advised that there had been consultation with the relevant GP who had not updated the computer at the surgery for the repeat prescription, so MAR sheet came to the home with no change. The change, consequently, had been made with some consultation with the GP but there was no audit trail to evidence this at the time of the site visit. The service user concerned was happy with arrangements, and there was no evidence that her needs or wishes were not being met. This omission appear to be a “one off”. As a result a recommendation will be made rather than a requirement on this occasion. St Catherines Residential Home DS0000011952.V311824.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): 12-13-14-15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents group had a wide range of needs and abilities. Some residents needed 24-hour supervision, and some residents could venture out from the home with no supervision. The staff at the home knew who could do what, and arrangements were in place to ensure service users independence was supported and encouraged in the area of lifestyles. One resident is a keen St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 14 football supporter, who attends matches on a regular basis, and has chosen to decorate his personal room around his interests. Residents explained that they had formed good friendships both at the home and prior to admission with other residents. Residents are supported to go out together into the local community, and less able residents are given staff support to go out. One visitor’s partner assisted with an outing recently with service users. Residents said they were free to choose what they did and when they did things. Residents were observed moving freely around their home, and were involved in activities of daily running, including helping lay tables, and tasks in the well kept garden. In general residents’ were found to be very satisfied with their lives at the home, and spoke highly of the support they received from the dedicated staff team. Service users confirmed that they received visitors at any reasonable time, and visitors also confirmed this. There is a small sign saying visitors are welcome at any reasonable time in the entrance hall area. Residents are encouraged and supported as far as possible to be part of their local community, and residents confirmed that this was the case. Residents are encouraged and supported to remain in control of their lives and are as fully involved as possible in any life decisions, taking control and making choices wherever possible. Where residents are unable to take full part in decision making effecting their lives, the home involves family and/or friends, or social services to act as advocate for the resident concerned. All residents spoken to said how good the food was at the home, and how much they enjoyed and looked forward to their meals. St Catherines Residential Home DS0000011952.V311824.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): 16-18 Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been no complaints since the last inspection of St Catherine’s. The pre-inspection questionnaire stated that no complaints had been made to the home since the last inspection. The CSCI had not received any complaints about the service since the last inspection. The complaints procedure is displayed in the entrance hall of the home, providing evidence of a pro-active, open approach toward complaints. Residents spoken to said that they knew who to speak to if they had any concerns, and felt confident that they could do so without repercussions. Visitors spoken to were aware of the complaints procedure, and of who they would need to speak to if they had any concerns. All relative and service user feedback forms stated that they had never had to make a complaint about the home. The service provides staff members with training in adult protection matters. Staff members were able to demonstrate an understanding of what may St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 16 constitute abuse, and of the action they would need to take if this were identified at the home. The home has a copy of the local adult protection policy and procedure, and managers were aware that the social services would be the lead agency in any investigation of adult abuse. Residents said they felt safe at the home. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 17 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): 19-23-26 Service users live in a safe, well-maintained environment. The degree to which service users’ sharing their own rooms and these arrangements suiting their needs will need to be kept under regular review. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well presented and well maintained, providing a valuing environment for residents. The building was homely, decorated in line with the wishes of the resident group, and residents had been supported to individualise their personal rooms. Communal areas were comfortable and warm, and efforts had been made to provide pictures, ornaments and mirrors to promote ordinary living, and to diminish any institutional feel. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 18 The main environmental challenge for the home is the high proportion of shared bedrooms. Currently 8 of the 14 beds are in shared bedroom. At the time of this site visit this was not and issue, as all residents sharing bedrooms had made a positive choice to share with each other. However, at least one service user would not wish to share if the person they currently shared with had to be changed. This will need to be identified in the service users assessment and care plan and contingency plans put in place to ensure a single room is made available in line with the national minimum standard 23.7 “When a shared place becomes vacant, the remaining service user has the opportunity to choose not to share, by moving into a different room if necessary.” The home was cleaned to a good standard, and was found to be hygienic and pleasant throughout. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 19 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 numbers of staff meets Service users needs. Further NVQ training is needed to ensure the skill mix meets the needs of residents and the standards set by government. Service users are in safe hands at all times. National benchmarks of the proportion of trained staff are not currently met. Service users are not fully supported and protected by the home’s recruitment policy and practices. Staff members are competent to do their jobs, but currently only 33 of a 50 target group are trained to the nationally recognized standards. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-inspection information provided by the owners of the home stated that only 33 of the staff team currently have NVQ level 2 training qualifications. The benchmark set by government since 2005 is for registered care services to have 50 of staff NVQ level 2 trained as a minimum standard. Mrs Afghan explained that three staff members would be enrolling on the NVQ level 2 course in mid-November 2006. When these staff members complete this training the home will meet training standards. The home has met these St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 20 standards in the past, but staff members move on, including qualified staff, and when this happens and unqualified staff members are taken on to replace trained staff, this leaves the service below standard. This issue may need to be considered in a wider context of how the home recruits and selects new staff, and retains trained/qualified staff in the future. However, in-house training covers essential baseline training with care staff and includes – • Moving and manual handling (M&MH) • First aid (FA) • Basic food hygiene (BFH) • Dementia awareness • Medication • Catheter care • COSHH (hazardous substances) training Further in-house training that is planned includes – • M&MH – updates • FA – updates • BFH – updates • Abuse and vulnerable adult training (POVA) • Infection control A sample of staff records were inspected and the following issues identified – Two staff members files failed to provide a clear audit trail, as required, to evidence that police / criminal records bureau (CRB) checks had been carried out. Mrs Afghan assured the inspector that these checks had been carried out but the paper work and evidence was being kept at the owner’s personal address. One staff member had been employed on the strength of two testimonials with out the owners having actively sought references as required. Residents’ spoke highly of the staff team and were appreciative of the care and support they received on a daily basis. Staff members and residents were observed to interact in a positive, caring and good-humoured way throughout the visit, and it was clear that good relations abound, and a genuine feeling of trust and care was evident. Visitors confirmed that staff members were always welcoming toward them and that they always witness good relations between staff members and service users. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 21 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): 31-33-35-38 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. The home is run in the best interests of service users. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mr Z Afghan is the registered manager of the service. Mr Afghan also has an assistant manager. Mr and Mrs Afghan and the assistant manager are currently all attending the “Registered Managers Award” (RMA) at a local college. Mr Afghan is a qualified and registered social worker and Mrs Afghan is a qualified and registered nurse. They have been involved in running registered care home now for a number of years, and have built up a good reputation locally as providers. There was clear evidence that service users feel empowered and involved in their home. While some of the methods of involving service users may be informal, they were found to be effective and commensurate to a smaller care home setting. More formal system of consultation have also been developed since the last inspection, and there are plans to build onto these systems in the future as a part of wider quality assurance measures. The inspector sampled resident personal allowance depositing arrangements at the home, as not all residents are able to manage their own financial affairs. These arrangements ensured that residents had money available when they needed it for such expenses as hairdressing, toiletries etc, and when staff are involved in administrating these matters records and receipts are maintained and valuables are kept safely under lock and key. The sample checked balanced accurately with the records. The home also involves relatives and encouraged them to support residents when appropriate and/or possible. The home had consulted a fire officer since the last inspection and had advised the CSCI of the outcome of this consultation. Fire precautions in place at the time of the visit appeared to be well maintained, and there are contracts with external companies who visit and test/maintain these arrangements safely in line with recommended international standards. Residents’ confirmed that there were regular fire tests and occasional fire drills at their home, which they were involved in. Residents were aware of what to do in the event of a fire. The pre-inspection questionnaire confirmed that all relevant contractors were employed to maintain such things as the homes central heating, fire and health and safety, and that record is kept. A sample of records in this area were also inspected and found to be up to date and accurate. The kitchen area is domestic in style, and consequently used for a number of other purposes than purely food preparation and cooking. However, there was no evidence that this was having an adverse effect on the maintenance of good food hygiene standards, and residents were being enabled to have access to their kitchen when they wishes and when this needed to be supervised, staff members were available. Because of the small size of the home staff often move across different roles in the home, but were found to be aware of the St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 23 need to take precautions against the risk of cross infection. As identified above the home is well maintained, and any breakages or general wear and tear are dealt with effectively and efficiently. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 24 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 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 2 X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 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 Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 25 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 OP28 OP30 Regulation 18-12 Schedule 2 19 – Schedule 2 Requirement The registered person must advise the CSCI in an action plan of how they intend to reach and maintain the staff training targets for the home. The registered persons must maintain records on the registered premises that provide an audit trail to evidence that the home’s selection and recruitment practices protect service users. Records must include references taken up by the home, at least one from the last employer, and proof that POVA and CRB have been checked and clearances received. Timescale for action 10/12/06 2. OP29 01/12/06 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.V311824.R01.S.doc Version 5.2 Page 26 1 OP9 1 OP23 It is strongly recommended that the registered persons ensure that medicine administration records are not changed without clear evidence and an audit trail of the agreement and the instruction of the prescribing doctor. It is recommended that the registered person with commissioners monitor and review the views of service users sharing bedrooms. In one case it will be necessary to have a contingency plan for a service user who has already stated that she will not be prepared to share a bedroom with anyone other than her current roommate. This will need to be put on the residents care plan and put on the agenda of care reviews with the SSD who commission her care service from the home. The provider may also wish to look into ways of reconfiguring the service in order to provide more single bedrooms at the home. St Catherines Residential Home DS0000011952.V311824.R01.S.doc Version 5.2 Page 27 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.V311824.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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