Inspection on 11/10/06 for St Catherines Rest Home,

This inspection was carried out on 11th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Catherines Rest Home, 14/06/07

St Catherines Rest Home, 07/10/05

St Catherines Rest Home, 09/05/05

St Catherines Rest Home, 09/12/04

St Catherines Rest Home, 14/05/04

St Catherines Rest Home, 19/12/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Catherines Rest Home, 15-17 Cann Hall Road Leytonstone London E11 3HY Lead Inspector Harun Rashid Unannounced Inspection 11th October 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 Rest Home, DS0000007231.V314908.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 Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherines Rest Home, Address 15-17 Cann Hall Road Leytonstone London E11 3HY 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) 020 8555 2583 020 8555 2583 Mrs Ann Ratcliffe Mrs Ann Ratcliffe Care Home 19 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: St. Catherines is a privately run care home registered to accommodate 19 elderly people. The home is situated in Cann Hall Road in Leytonstone, in the London Borough of Waltham Forest. The home is located in a residential area within easy access to community resources. There are two double bedrooms and 15 single bedrooms. The home provides five single bedrooms and two double bedrooms with en-suite facilities. The home currently employs 15 care workers (full-time and part-time), two parttime cooks, one handyman and one domestic assistant. The manager arranges service users activity programmes. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a weekday morning on 11th of October 2006. The Inspector was able to speak to nine service users and one service user’s son who visited the home during the inspection. The Inspector interviewed four members of staff including the deputy manager. The registered manager and the proprietors were present for the part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered manager is required to include the address and the telephone number of the CSCI (Ilford) local office in the Statement of Purpose and in the Service Users’ Guide as CSCI Stratford office moved to Ilford. The registered manager must ensure that all service users sign contracts with the management of the home. The registered manager to complete her NVQ level 4 qualifications in management. The registered manager must publish the results of the service users satisfaction questionnaires and made this available to all relevant parties. The registered manager is required to seek advice for five service users placing authorities to manage their finances in accordance with Regulation 20 of the Care Homes Regulations 2001. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 6 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 Rest Home, DS0000007231.V314908.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 Rest Home, DS0000007231.V314908.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 The quality in this outcome is adequate. This judgement had been made using available evidence including a visit to this service. The home has developed a statement of purpose and a service users’ guide, however, this is required to amend. Service users were provided with contracts, however, it is required that all service users sign contracts. The home has carried out pre-admission assessments of service users and are able to meet their identified needs. EVIDENCE: The Statement of Purpose included the aims, objectives and information about the service. The Service Users’ Guide included information about the home and the service it provides. However, The registered manager is required to include the address and the telephone number of the CSCI (Ilford) local office in the Statement of Purpose and in the Service Users’ Guide as CSCI Stratford office moved to Ilford. Service users are provided with written contracts/statement of terms and conditions with the home. However, evidence suggests that all service users have not signed the contracts. The deputy manager advised that there is St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 9 difficulty around signing contract by a particular service user. The inspector advised that if any service user is unable to sign the contract then, a family member or an advocate must sign the contract on behalf of a service user. Three newly admitted service users care files confirmed that the management has carried out pre-admission assessments prior to the admissions. The preadmission assessments were detailed with information, which covered all areas of needs. The home is currently accommodating 18 service users including eight service users with dementia diagnosis. Staff were provided training on dementia awareness and a training called ‘ yesterday, today, tomorrow training in dementia care’. Staff interviewed and daily records suggest that they were able to meet the specialist needs of service users. A district nurse visits a service user three times a week to change his dressing on an ulcerated leg. The district nurse also monitor and test blood sugar level of a service user who was diagnosed for diabetics. Service users who have mobility problems were provided Zimmer frames to encourage their mobility. Newly admitted service users had opportunities to visit the home prior to the admission. The deputy manager informed that they have visited the home and they were introduced to other service users, members of staff, shown the bedrooms and had meals with service users. One service user had three weeks respite services prior to the permanent move to the home. In addition to this, social workers and service users family members also visited the home. The home does not provide the intermediate care; therefore standard six is not applicable to this service. St Catherines Rest Home, DS0000007231.V314908.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this outcome is good. This judgement had been made using available evidence including a visit to this service. All service users have individual care plans and these are reviewed on a monthly basis. The home ensures that service users health care needs are met. Service users are treated with respect and their privacy is maintained at all times. EVIDENCE: Care files examined confirmed that care plans were developed from the information gathered from all assessments carried out by the home and information received from social workers and health professionals’ assessment reports. Evidence suggests that the home review care plans on a monthly basis. Staff escort service users to all medical appointments for example; G.P and dental. Some cases health professionals’ visits service users at home. Service users receive visits from district nurses for various health care needs, for example, a service user is required to change dressing on his leg at least three times a week, another service user is required district nurse’s input for the management of her diabetes. The home provided pressure relieves equipments for a service user who is suffering from pressure area problems. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 11 All medication is supplied in blister packs by a local chemist. Staff administer medications to service users maintain records in the Medication Administration Record (MAR) sheets. MAR sheets were examined and found to be satisfactory. Staff interviewed confirmed that they have attended medication administration training. The Pharmacist also visits the home once a month and carry out monthly audits. Staff interviewed informed that they promote service users privacy and dignity at all times. It was observed that bedroom doors were shut during the delivery of persona care. Medical examinations take place in private in service users bedrooms. Service users have access to telephones for use in private; they can use the pay phone and the office phone. St Catherines Rest Home, DS0000007231.V314908.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome is good. This judgement had been made using available evidence including a visit to this service. The home organises group and individual activities for service users. Friends and family members are welcomed by staff. Service users are encouraged to visits places of their interest. A choice of menu is provided. EVIDENCE: The management organises individual and group activities for the service users. An entertainer visits the home to conduct music programme on a fortnightly basis. Staff arrange music session and gentle exercise. The inspector observed the bingo and board game sessions on the day of inspection. Service user are encouraged to attend church. On the day of inspection a service user received visitors from a church. Service users family members visit them on a regular basis. Service users are able receive their visitors in private in their bedrooms or in the office room. Staff welcome family and friends at home. The inspector interviewed a service user’s son who visits his father on a regular basis. The home encourages service users autonomy and choices. One service user manages her finances and she is encouraged to travel independently. This service user informs the inspector that she like travelling into the local St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 13 community. Another service user who loves travelling in the community said to the inspector that despite he had an imputed leg he loves travelling and wishes to continue to visit to Kent for respite/holiday. Service user are encouraged to bring their personal items with them when they move in to the care home. Family members advocate for their relatives, however, information regarding access to ‘ Care Aware’ advocacy services were available for service users and family members. The home employs two part-time cooks who cook service users meals. Evidence suggests that service users are consulted before developing four weekly menu plans. Service users are provided menus of choice. They receive a varied, appealing, wholesome and nutritious diet. Service users are provided a variety of meals as the current service users come from a various ethnic communities. St Catherines Rest Home, DS0000007231.V314908.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome is good. This judgement had been made using available evidence including a visit to this service. The complaint policy and procedure of the home is simple and clear. The adult protection policy and procedures contains sufficient guidance for staff to protect service users from abuse. EVIDENCE: The home has a complaint policy and procedure in place. The home maintains a complaint book, which was seen. Since the last inspection one complaint was received from a service user’s friend, which was dealt with appropriately. The CSCI has not received any complaint since the last inspection. All staff attended adult protection training. Staff interviewed informed that they have read the home’s adult protection policy and procedures. Staff showed their awareness of adult protection issues. The registered manager informed that she has referred a service user’s relative to the Waltham Forest adult protection team who failed to pay weekly personal allowances to his aunt. St Catherines Rest Home, DS0000007231.V314908.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality in this outcome is good. This judgement had been made using available evidence including a visit to this service. The home is suitable for its stated purpose. It is safe and well maintained. The home is clean, hygienic and free from offensive odour. EVIDENCE: St. Catherine is located within easy access of community resources, which includes local shops and public transport. There is a rolling programme for maintenance and a record is maintained of works carried out. The home is suitable for its stated purpose for the current service users accommodated in the home. A tour of the premises was conducted during the inspection. The premises were found free from offensive odour. The kitchen was found very clean and tidy. Staff keep records of fridge and freezer temperature. The home is safe and comfortable. Staff interviewed confirmed that they have attended infection control training. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome is good. This judgement had been made using available evidence including a visit to this service. The home operates a thorough recruitment procedures based on equal opportunity policy and carry out all relevant checks on staff before recruitments. The home provides staff training for its staff development. EVIDENCE: Staff rota was viewed which confirmed that four members of staff were in duty in the morning shift including the deputy manager. The home currently employs 15 (full time and part time) care staff and 4 ancillary staff (2 parttime cooks, 1 domestic assistant and 1 handy man in order to support care staff in their work. The staff rota confirmed that two members of staff are on duty at night. The home offers student placements for work experiences. Staff files contained NVQ level 2 qualification certificates. More than 50 of care staff have already completed their NVQ level 2/3 qualifications in care. The home is encouraging it’s all staff to attend NVQ level 2 training in care. The deputy manager has recently completed her RMA qualification and anticipating completing her NVQ level 4 training in care. The management operates a thorough recruitment procedures based on equal opportunities. Staff files were examined which confirmed that the registered manager obtains two reference letters and carries out all relevant checks including the CRB disclosures before employing any new staff. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 17 The home encourages its staff to attend NVQ level 2/3 training in care. The deputy manager and staff interviewed informed that all staff have opportunities at attend various training through distance learning and by attending courses. Staff were provided training on dementia awareness and a training called ‘ yesterday, today, tomorrow training in dementia care’ by the Alzheimer society. In addition to this staff have completed first aid, health & safety, food hygiene, moving and handling, infection control, elder abuse and medication administration training. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 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): 31,33,35, 36 and 38 The quality in this outcome is adequate. This judgement had been made using available evidence including a visit to this service. The home ensures service users health, safety and welfare. Staff receive regular supervision and staff meetings take place on time. The registered manager to complete her NVQ level 4 qualifications in management. EVIDENCE: The registered manager is also the proprietor of the home. She is managing the home since it was opened in 1988. She is supported by her husband who is a joint proprietor. In addition to this the manager is well supported by the deputy manager. Staff interviewed informed that the deputy manager supports them. However, the registered manager to complete her NVQ level 4 qualifications in management. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 19 The home obtains service users’ satisfaction survey questionnaires on a periodic basis. However, the results of this year’s service users satisfaction questionnaires to be published. The management informed that 12 service users finances are managed by their family members and one service user manage her own finance. Remaining five service users finances are paid out to ‘St. Catherine’s Residents Club’. The proprietor and the registered managers are the joint signatories. They keep records of all financial transactions electronically and this was shown to the inspector. However, the registered manager is required to seek advice for those five service users placing authorities (the London Borough of Waltham Forest and the London Borough of Newham) to manage their finances in accordance with Regulation 20 of the Care Homes Regulations 2001. Staff interviewed and staff files were examined confirmed that they receive a minimum of six individual supervision by their line managers. All staff receive annual staff appraisals. The manager ensures that regular staff meetings takes place and staff have opportunities to raise issues in the meetings. Staff informed that they work as a team and support each other. It was evident from discussion with staff, management and from the examination of documentations that the management ensures service users and staff health, safety and welfare. Staff attended moving and handling, fire safety, first aid, food hygiene, elder abuse and infection control training. Regular checks are carried out on gas and electric appliances. All inspection certificates were kept in a folder and this was available for inspection. The home has a valid insurance cover against loss or damage to the assets of the business. St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 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 2 2 3 3 3 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 2 x 2 x 2 x x 3 St Catherines Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 21 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 OP1 Regulation 4&5 Requirement The registered manager is required to include the address and the telephone number of the CSCI (Ilford) local office in the Statement of Purpose and in the Service Users’ Guide as CSCI Stratford office moved to Ilford. The registered manager must ensure that all service users sign contracts with the management of the home. The registered manager to complete her NVQ level 4 qualifications in management. (This is an outstanding requirement and this will be assessed at the next inspection.) The registered manager must publish the results of the service users satisfaction questionnaires and made this available to all relevant parties. The registered manager is required to seek advice for five service users placing authorities to manage their finances in accordance with Regulation 20 of the Care Homes Regulations 2001. DS0000007231.V314908.R01.S.doc Timescale for action 31/03/07 2. OP2 5 31/03/07 3. OP31 9 31/03/07 4. OP33 24 31/03/07 5. OP35 20 31/03/07 St Catherines Rest Home, Version 5.2 Page 22 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 Rest Home, DS0000007231.V314908.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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