Inspection on 14/06/07 for St Catherines Rest Home,

This inspection was carried out on 14th June 2007.

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 Rest Home, 11/10/06

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 Rob Cole Unannounced Inspection 14th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherines Rest Home, DS0000007231.V340086.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.V340086.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 stcathscare@yahoo.co.uk Mrs Ann Ratcliffe Mr Keith Ratcliffe Lavinia Cassidy Care Home 19 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 19 11th October 2006 Date of last inspection 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. As well as care staff, the home also employs designated cooking and cleaning staff. The home is privately run. St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 14/6/07 and was unannounced. The inspector had the opportunity of speaking with service users, their relatives, staff from the home and the homes manager was present throughout the inspection. The inspection also included a tour of the premises and an examination of records and documents, along with an observation of the care and support provided. Overall, the inspector believes that the care and support provided is of a generally satisfactory standard, although there are a number of issues that need to be addressed, as highlighted within this report. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still a number of issues that must be addressed. The home must ensure that medications are administered and recorded appropriately as a matter of priority. All staff must receive regular formal supervision. The home must ensure that it has appropriate policies and procedures in place around adult protection issues. St Catherines Rest Home, DS0000007231.V340086.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. The summary of this inspection report can be made available in other formats on request. St Catherines Rest Home, DS0000007231.V340086.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.V340086.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose, this states that the aim of the home is “To foster an atmosphere of care and active support which both enables and encourages our residents to live as full, interesting and independent lifestyle as possible enabling participation and inclusion.” The Statement included details of services and facilities provided and details of the staff team and their qualifications. The Statement is written in plain English. However, the manager St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 9 informed the inspector that this and other documentation has not been produced in a format which is easily accessible to all service users. The manager informed the inspector that documentation produced in large print or audiotape would be more accessible to service users. It is required that key documentation is produced in a format which is most easily accessible to service users. The home also has a Service User Guide in place. This was in line with National Minimum Standards (NMS). Both the Guide and the Statement of Purpose have been dated, and are subject to regular review. Since the last inspection they now contain accurate contact details of the CSCI. Contracts/statements of terms and conditions are in place for all service users. Since the previous inspection these have now been signed by the inspector and a representative of the home. They include details of fees payable, what fees cover and what is extra. The home has an admissions procedure in place. This states that service users will be given the opportunity of visiting the home before making a decision as to move in or not. Service users and their family spoken to confirmed that they were indeed given this opportunity. There was evidence that the manager carries out a pre admission assessment on all service users prior to them moving into the home, in addition to any information provided by the local authority. These assessments covered needs associated with mobility and personal care. Service users initially move into the home on a trial basis. The home does not provide intermediate care. St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home is generally able to meet the personal care needs of service users, more attention needs to be paid to meeting their health care needs, especially with regard to the administration and recording of medication. EVIDENCE: Individual care plans are in place for all service users. These are subject to monthly review, and are drawn up with the involvement of the service user, their keyworker and the homes manager. Plans were however of a variable standard. For the more recent service users, plans were sufficiently detailed and comprehensive. They included issues such as mobility, personal care, and equalities and diversity issues such as sexuality and disability. For others, care plans were not so detailed, and contained very little information around St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 11 diversity issues. It is required that all care plans are clear and comprehensive, clearly setting out how the home can meet all the assessed needs of service users. Risk assessments are in place for all service users. These are subject to regular review, and were of a satisfactory standard. They covered risks associated with mobility and pressure sores, and included strategies to manage and reduce any identified risks. All service users are registered with a GP, the manager informed the inspector that service users are able to maintain the GP they had prior to admission to the home where this is practical. The manager informed the inspector that service users have access to health care professionals as appropriate, including routine access to dental and eye care. However, no clear records are maintained of medical appointments, and it is required that the home maintains records of medical appointments, including who the appointment was with, the reason for the appointment, the date of the appointment and details of any follow up action necessary. The district nurse provides advice on continence issues. Used continence products are stored in yellow bags, but these are not kept in a bin, but in a small outdoor alcove, behind iron railings. The manager informed the inspector that they had spoken to someone at the London Borough of Waltham Forest, who had advised that the local authority would not collect used continence products from bins due to concerns around lifting and handling. However, this approach is not consistent across the borough, and it is required that the home seeks the advice of the Local Authorities Environmental Health Department in writing on the storage of used continence products prior to their collection. The home has a medication policy in place. During the daytime all medications are administered by staff who have undertaken training in the administration of medications. However, not all night staff have had such training, although service users are currently prescribed medication to take at night. On occasions the rota indicated that there were no staff on duty who had had any training, and medication records indicated that medication had been administered by staff without training. The manager confirmed that this was indeed the case. It is required that all staff who have a responsibility for administering medications first undertake appropriate training, including an assessment of their competence. No service users currently self medicate, or are on any controlled drugs. Medications are stored securely in a locked cabinet. The home maintains Medication Administration Record (MAR) charts. However, those examined by the inspector contained several unexplained gaps, thus making it impossible to verify if the medication on those occasions had been administered as appropriate. It is required that all medications are administered and recorded as appropriate. The MAR chart for one service user indicated that they had been prescribed DIAZEPAM, and that they were to take one tablet daily, yet the label on this medication said take one tablet daily as St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 12 required. It is required that information on MAR charts is consistent with information on medication labels, and that both are in line with the prescribing instructions of the medical practitioner who prescribed the medication. Through observation and discussion there was evidence that the privacy and dignity of service users is promoted. Staff were observed to interact with service users in a respectful and friendly manner, and service users informed the inspector that staff treated them well. The homes Statement of Purpose states that service users are supported to maintain their independence as much as possible, and care plans indicated that service users are encouraged to manage their own personal care as much as possible. Staff were observed to knock and wait before entering bedrooms. The home has sought and recorded the wishes of service users on the arrangements to be made in the event of their death. The homes manager informed the inspector that service users could remain in the home with a terminal illness, so long as the home could meet their medical needs. St Catherines Rest Home, DS0000007231.V340086.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live valued and fulfilling lives. Food was of a good standard, and a variety of social and leisure activities are provided. EVIDENCE: The home arranges for a variety of social and leisure activities to take place in the home, and there was evidence that service users are able to access the community. As well as meeting service users leisure needs, many of these activities also help to meet service users needs around equalities and diversities issues, such as around their age or culture. In house, the home provides various activities, such as TV, music, dominoes and bingo. Other activities include enabling service users to be involved with cooking and gardening in the home. A range of professional entertainers visit the home, who put on shows and various sing-a-long sessions. On the day of inspection there was a poster on display advertising a forthcoming show. Gentle exercises St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 14 classes are held twice a week, service users spoken to informed the inspector that they very much enjoyed these sessions. The home arranges various craft sessions, including painting, and examples of paintings by service users were on display within the home. The home also organises a regular reminiscence group. In the community service users visit local shops, parks, pubs and hairdressers. Occasional day trips are arranged, for example to Southend, and service users visit a Caribbean day service. One service user visits a Jehovah Witness Kingdom Hall, whilst a priest visits the home on occasions. There was evidence that service users have control over their daily lives, and that they are involved in the day to day running of the home, for example with planning menus. Regular service user meetings are held, minutes are maintained of these meetings, the most recent meeting discussed plans for activities and the homes complaints procedure. One service user recently had their bedroom decorated, and the service user was involved in choosing the décor. During the course of the inspection, the inspector had the opportunity of speaking with several visiting relatives. Relatives informed the inspector that they were able to visit at any time, and were always made welcome by the home. They are able to see service users in private. Service users are also able to maintain contact with relatives by phone, and are given their own mail to open. The home keeps a compliments book, which included various letters from relatives, one wrote “I wish to express how happy we are with the care and attention given to my mother.” The home maintains a record of its menus, and the day’s menu was on display in the lounge in picture form. Menus indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection there was a choice of meatloaf or chicken and vegetable pie. Food appeared appetizing, and service users informed the inspector that they enjoyed it very much. Menus indicated that the home regularly provided Caribbean food, as well as traditional British food. Mealtimes were observed to be unhurried and relaxed, and where service users needed support with eating, this was seen to be provided in a sensitive manner. Service users were offered drinks and snacks throughout the day. Fresh fruit was available, and there was evidence that the home routinely uses fresh produce in its cooking. The kitchen was clean and tidy, and food was stored appropriately. The home employs designated cooking staff, and all staff who have responsibility for food preparation have undertaken food hygiene training. Records are maintained of fridge and freezer temperatures. St Catherines Rest Home, DS0000007231.V340086.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has appropriate policies in place around complaints, it must ensure that appropriate policies and procedures are also in place around adult protection, to help ensure that service users are safeguarded from the risk of abuse. EVIDENCE: The home has a complaints log, this indicated that complaints received are appropriately recorded and investigated. There was also a complaints procedure in place, a copy of which was on display within the home. Service users and relatives spoken to demonstrated a good understanding of whom they could complain to if they so wished. The procedure included timescales for responding to any complaints received, and contact details of the CSCI. The home does not have a copy of the Local Authorities adult protection procedure, and must obtain a copy. The home did have its own adult protection procedure in place. However, this was not in line with current legislation. For instance, the procedure does not state that the home has a responsibility to inform the Local Authority of any allegations of abuse. This must be addressed. The manager informed the inspector that all but one of the St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 16 staff employed at the home have undertaken training in adult protection issues, and that is was planned that the remaining staff member will undertake this training in the near future. The inspector was satisfied that service users legal rights are protected, for example all service users are on the electoral register, and service users are able to vote in elections. St Catherines Rest Home, DS0000007231.V340086.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to the physical environment. The home was generally well maintained, and service users have access to adequate communal and private space. EVIDENCE: The home is situated in the Leytonstone area of the London Borough of Waltham Forest. It is in a quiet residential area, close to shops, transport networks and other local amenities. The home consists of two houses that have been converted into one, and is built over two floors, with a service lift connecting the floors. It is in keeping with other homes in the area. St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 18 The home was generally well maintained, both externally and internally. Communal furniture was well maintained and domestic in character. Communal areas consist of a lounge, another lounge/dining area, the kitchen and the homes garden. This was well maintained, and included appropriate garden furniture. Service users were seen to be enjoying spending time in the garden on the day of inspection. It was observed that service users have unrestricted access to communal areas of the home. The home had adequate numbers of toilets and bathing facilities, with a choice of bath or shower. Bathrooms were clean, tidy and free from offensive odour, and all had impermeable floor coverings. All bathrooms had locks fitted, however, the lock on one on the first floor toilets did not have an emergency override device fitted, and it is required that all bathrooms and toilets have locks fitted which include an emergency override device. The home is registered for nineteen service users, and comprises fifteen single bedrooms and two double bedrooms. Seven of the bedrooms have ensuite facilities, while all the others include a hand basin. Bedrooms meet National Minimum Standards on room sizes. Service users have been able personalise bedrooms to their own tastes, for example with televisions and family photographs. They contained adequate furniture, including table, chair, chest of draws and wardrobes. Bedding, carpets and curtains were well maintained and domestic in character. Bedrooms have adequate natural light and ventilation, and all had central heating. Radiators have appropriate protective coverings. Emergency alarm call points were installed in all bedrooms and bathrooms. The inspector tested two of these, and on both occasions there was a prompt response from staff. Bedrooms were clean and tidy, however, two bedrooms had an offensive odour, and this must be addressed. It was also found that there was no screening provided in the two double bedrooms, this must also be addressed. The home has various adaptations in place to help make it accessible to service users. As mentioned, there is a service lift between the two floors, and the home uses hydraulic hoists. Toilets have handrails fitted, and baths and showers have both been adapted to make them accessible to service users. The home has taken steps to help prevent the spread of infection. Staff have undertaken training in infection control, and protective clothing such as gloves and aprons are available to staff. The home has laundry facilities suitable in scale for the home. Hand washing facilities are situated around the home, and COSHH products were stored securely. St Catherines Rest Home, DS0000007231.V340086.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the inspector believes that the home is staffed in sufficient numbers to meet service users needs, it must ensure that all appropriate employment checks are carried out for all staff at the home. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staff rota on display, this accurately reflected the staffing situation on the day of inspection. However, it did not indicate who was in charge of the home at any given time, and this must be addressed. All staff are provided with a copy of their job description, the General Social Care Council codes of conduct and a copy of the homes staff handbook. Staff spoken to demonstrated a good understanding of their roles and responsibilities, and through observation there was evidence that staff have built up good relations with individual service users. Regular staff meetings are held, and all staff are able to contribute to the agenda. St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 20 The home has various employment policies in place, including on recruitment and selection, equal opportunities, grievance and disciplinary procedures. CRB’s were in place for all staff, however, for three staff these were from a previous employer. CRB’s are not portable, and it is required that the home carries out a CRB check on all staff who work at the home. It was also found that the home did not have two written references in place for all staff, and that the home did not have a full written employment history in place for all staff. All of this must be addressed. The home did have appropriate ID checks in place for staff. Of the fourteen care staff employed at the home, eleven have achieved a relevant care qualification, and the remaining three staff are currently working towards such a qualification. Staff have access to regular training, recent training includes first aid, food hygiene, oral care, manual handling, dementia, adult protection and health and safety. It is planned that staff will undertake training around the Mental Capacity Act in the near future. St Catherines Rest Home, DS0000007231.V340086.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the manager is suitably qualified and experienced to carry out their duties. However, more attention needs to be paid to some areas, notably the supervision of staff. EVIDENCE: The homes manager was first registered with the CSCI in April 2007. They have twenty years experience of working with older persons, including three years in a managerial capacity. They have achieved the Registered Managers Award and a NVQ Level 4 in Care. Staff were observed to interact with the St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 22 manager in a relaxed manner, and staff and service users informed the inspector that they found the manager to be approachable and accessible. Staff meetings, care plan reviews and service user meetings contribute to the quality assurance within the home. Copies of previous inspection reports were available to view in the home. The home issues questionnaires to service users and their relatives to gain their feedback on the running of the home, those completed questionnaires seen by the inspector contained generally positive feedback. However, there was no evidence that Regulation 26 visits take place. These must be carried out monthly and be unannounced. A copy of the report of these visits must be forwarded to the CSCI, and a copy must be retained in the home. The home holds money on behalf of service users. Records and receipts are maintained of any monies spent on their behalf. Those records inspected appeared to be satisfactory. Formal staff supervision within the home is very sporadic. Where it has taken place, notes are taken, and staff have access to these notes. There was evidence that supervision covers appropriate topics, such as service user issues and training needs. However, some staff have not had any formal one to one supervision at all in the past twelve months, and it is required that staff receive regular formal supervision, at least six times a year. Fire extinguishers were situated around the home, these were last serviced in December 2006. Fire exits were free from obstruction on the day of inspection. Fire alarms in the home are tested on a weekly basis, and were last serviced on the 11/4/07. The home has a comprehensive fire risk assessment in place. However, the home has not held regular fire drills, and it is required that fire drills are held at least once every three months. There was evidence that the service lift and hydraulic hoists are serviced as appropriate. The home had in date certificates for gas safety, PAT testing and electrical installation. COSHH risk assessments were in place, and COSHH products were stored securely. The home had a well stocked first aid box. Hot water temperatures in the home had not been checked since March of this year, and it is required that all hot water outlets used for personal care are checked at least once a week, to ensure that they are 43 degrees centigrade. The home has in date employer’s liability insurance cover in place. St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 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 3 18 2 3 3 2 3 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 2 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 Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 and 5 Requirement The registered person must ensure that the homes Statement of Purpose, Service User Guide and other key documentation is produced in a format which is most easily understood by service users. The registered person must ensure that all service users have comprehensive care plans in place, covering all areas of need, including needs around diversity and equalities issues. The registered person must ensure that clear and comprehensive records are maintained of all medical appointments, including details of any follow up action necessary. The registered person must ensure that the home seeks the advice on the Local Authorities Environmental Health Department in writing on the safe storage of used continence products prior to their collection from the home. Timescale for action 30/09/07 2. OP7 15 31/08/07 3. OP8 13 31/07/07 4. OP8 13 and 23 31/07/07 St Catherines Rest Home, DS0000007231.V340086.R01.S.doc Version 5.2 Page 25 5. OP9 13 and 18 6. OP9 13 7. OP9 13 8. OP18 13 9. OP18 13 10. OP21 23 11. OP24 23 12. 13. OP24 OP27 23 17 The registered person must ensure that all staff with responsibility for the administration of medications undertake appropriate training in medication issues, which includes an assessment of their competence. The registered person must ensure that all medications are appropriately administered and recorded. The registered person must ensure that prescribing instructions on Medication Administration Record charts are consistent with those on the medication label, and that both are in line with the prescribing instructions of the medical practitioner who prescribed the medication. The registered person must ensure that the home has a copy of the Local Authorities adult protection procedure. The registered person must ensure that the home has an adult protection procedure which is in line with current legislation. The registered person must ensure that all bathrooms and toilets in the home are fitted with a working lock, that includes an emergency override device. The registered person must ensure that the home provides appropriate screening in all double bedrooms occupied by two people. The registered person must ensure that all bedrooms are free from offensive odours. The registered person must ensure that the staff rota clearly identifies who is in charge of the home at any given time. DS0000007231.V340086.R01.S.doc 30/06/07 30/06/07 30/06/07 31/07/07 31/07/07 31/08/07 31/07/07 30/09/07 30/06/07 St Catherines Rest Home, Version 5.2 Page 26 14. OP29 19 15. OP33 26 16. OP36 18 17. OP38 13 and 23 18. OP38 13 and 23 The registered person must ensure that all appropriate employment checks are carried out on all staff working at the home, including CRB’s, employment references a full written records of staff’s employment history. The registered person must ensure that monthly Regulation 26 visits are carried out, and that a copy of the report of these visits is forwarded to the CSCI, and a copy is retained within the home. The registered person must ensure that all staff receive regular formal one to one supervision at least six times a year. The registered person must ensure that the home holds regular fire drills, at least once every three months. The registered person must ensure that all hot water outlets used for personal care are tested weekly to ensure that the water temperature is 43 degrees centigrade. 30/09/07 31/07/07 31/08/07 30/06/07 30/06/07 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.V340086.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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