Inspection on 07/10/05 for St Catherines Rest Home,

This inspection was carried out on 7th October 2005.

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 Rest Home, 14/06/07

St Catherines Rest Home, 11/10/06

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 7th October 2005 10:00am 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 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 Version 1.10 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 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 stcatherines2003@yahoo.co.uk Mrs Ann Ratcliffe Mrs Ann Ratcliffe Care Home Nineteen (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 (19) St Catherines Rest Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 9th May 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 care hours are provided from 8am to 8pm with a minimum of three staff on duty and two waking night staff during the night. The home employs a full time cook, a handyman and the manager/proprietor arranges service users activity programmes. St Catherines Rest Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a weekday on 7th of October 2005. The Inspector was able to speak to eight service users and two family members who visited the home during the inspection process. The Inspector interviewed three members of staff including the deputy manager. The registered manager was on holiday at the time of the inspection. They all expressed their satisfaction with the standards of care provided in the home. The service applied for a major variation for dementia category, which was successful. A certificate of registration was issued in June 2005. At the time of the inspection the home accommodated two service users with dementia care needs. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherines Rest Home Version 1.10 Page 6 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 Standards Statutory Requirements Identified During the Inspection St Catherines Rest Home Version 1.10 Page 7 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 standard(s) 1, 2,3 and 6 The home provides a Statement of Purpose and Service Users’ Guide. Service users’ were provided with contracts. The home ensures that all prospective service users assessment of needs is carried out before admission. The home does not provide intermediate care. EVIDENCE: The Statement of Purpose and the Service Users’ Guide were amended on 1/7/05 following the recommendation. The service was granted the dementia category on 28th of June 2005. The Statement of Purpose and the Service Users’ Guide included all areas listed in the National Minimum Standards. The Statement of Purpose and the Service Users’ Guide were available for inspection and to service users and family members. Service users’ were issued contracts by the management of the home and signed by the proprietor and the service users or their family members. The written/statement of terms and conditions with the service users’ and the home meet the standards. St Catherines Rest Home Version 1.10 Page 8 From the examination of four care files and discussion with the deputy manager it was clear that the proprietor/registered manager or the deputy manager undertakes a full and comprehensive assessment for all prospective service users to ensure they can meet individual assessed needs. For all individuals referred through care management arrangements the manager ensures she obtains a comprehensive assessment of care needs and a copy of the care plan. The home does not provide intermediate care. Therefore, this standard is not applicable to this service. St Catherines Rest Home Version 1.10 Page 9 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 standard(s) 7,9 and 10 The home ensures that service users health needs are assessed and work in partnership with health professional to meet these assessed needs. Staff treat service users with respect and ensure their privacy. The registered manager must ensure that all medication administration is recorded immediately after the administration of medication. EVIDENCE: From the examination of care files it was clear that service users care plans were generated from comprehensive assessment of the care managers and homes own assessments. Two newly admitted service users with dementia had comprehensive assessment and care plans available in the care files. Care plans set out the detailed information that show how and by whom the assessed needs would be met. Staff complete ‘residents daily report records’ which show how care plans were implemented. Staff work in partnership with health professionals for example, district nurse to meet service users assessed needs. The deputy manager informed that six members of staff have completed a ‘care planning and documentation’ distance learning course. The home reviews service users care plans on monthly basis. St Catherines Rest Home Version 1.10 Page 10 The deputy manager advised that they have met all requirements and recommendations made by the CSCI Pharmacist Inspector on 7/12/04. However, at the time of the inspection the Inspector examined the Medication Administration Record (MAR) Sheets (at 11.30am) and found that staff did not record 8 am medication administration on MAR sheets. The Inspector pointed this out to the deputy manager. She had mentioned this to staff immediately. It is required that administration of medications must be recorded on Medication Administration Record sheets immediately after medications are administered to service users. From the Inspector’s observation, discussion with staff and the deputy manager it was evident that staff respect service users and offer privacy and dignity when providing personal care. Four of the service users share two double bedrooms and mobile screen are provided to ensure their privacy in the bedroom. Service users have access to a pay phone and they can use the office to make a private call. St Catherines Rest Home Version 1.10 Page 11 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 standard(s) 14 and 15 The home encourages service users autonomy and enables them to make choices. Choices of menus are offered at mealtimes. EVIDENCE: The care plans identified how service users used their autonomy, and made choices and these would be met. Staff support service users with individual shopping tasks and visits to a local hairdresser. Service users have access to their personal records if they wish to see them in accordance with the Data Protection Act 1998. Service users and their family members were given information regarding ‘Care Aware’ free advocacy services. Two service users relatives spoken to were satisfied that their relatives choice was promoted. From the examination of weekly menus and discussion with service users and staff it was clear that they receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements. The weekly menu offers choices of at least two meals at each mealtime. St Catherines Rest Home Version 1.10 Page 12 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 standard(s) 16,17 and 18 The complaint policy and procedure of the home is simple and clear. This was available to all relevant parties. Adult Protection policy and procedures contain sufficient guidance for staff to protect service users from abuse. EVIDENCE: The home has a simple and clear complaint policy and procedure and this was made available to all relevant parties. At the time of the inspection two service users relatives spoken to were aware of the complaint procedures. They confirmed that the manager/deputy manager who is at the home most of the time always listen to their complaints and try to resolve these as soon as possible. Service users are on the electoral register. Some of the service users apply their citizenship right and vote in the elections. Some of them cast their votes by post. The deputy manager informed that service users and their family members were given information how to access advocacy services such as Age Concern or Care Aware. All staff attended Adult Protection training. Staff interviewed were aware of the Adult Protection policy and procedures of the home. The registered manager was aware of her responsibility to refer staff who harm service users in their care to POVA list. St Catherines Rest Home Version 1.10 Page 13 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 standard(s) 19 and 26 The home is suitable for its stated purpose. The home was clean, hygienic and free from offensive odour. EVIDENCE: St. Catherine’s 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 accommodate. Following the recommendation of the previous inspection report (dated 9/12/04) and the Health and Safety Manager of Waltham Forest a handrail on the wall to the staircase is provided. The deputy manager advised that they have meet all requirements and recommendations made by Registration Inspectors in order to obtain the dementia category. St Catherines Rest Home Version 1.10 Page 14 At the time of the inspection, the premises were clean, fresh and bright with no offensive odour. The kitchen was very clean and tidy with well-organised storage facilities. The washing machine has specified programming ability to meet disinfection standards. St Catherines Rest Home Version 1.10 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 At the time of the inspection the number of staff was sufficient to meet service users current needs. However, the management is recommended to review their staffing level from time to time in line with service users assessed needs. Staff attended dementia care and NVQ level 2 training in care. The management to ensure that staff files are available for inspection. EVIDENCE: At the time of inspection three members of staff in addition to the deputy manager was on duty. The home currently employs 17 (full time and part time) care staff and 4 ancillary staff in order to support care staff in their work. The staff rota confirmed that two members of staff are on duty at night. The Inspector advised the management that they should review their staffing level following the change of category (dementia) in line with the service users assessed needs. The home offers student placement for NVQ level 2 in care for Barking and Dagenham College. The deputy manager also informed that a diploma in social work student also had a placement recently. The deputy manager advised that ten members of staff have completed their NVQ level 2 qualifications in care and five staff will commence their NVQ level 2 training this year. The deputy manager is currently undertaking her RMA qualification and completed eight units out of twelve. She anticipates completing the remaining units by the end of this year. The management operates a thorough recruitment procedures based on equal opportunities. The deputy manager advised that they always receive two St Catherines Rest Home Version 1.10 Page 16 references for each staff member before appointing to the posts. The manager ensures that all staff have a current CRB disclosure. However, at the time of the inspection these documents were not available for inspection due to the fact is that the registered manager was on holiday. The deputy manager had no access to these documents. The deputy manager advised that members of staff have attended Elder Abuse and dementia awareness training. In addition to this five staff have attended a 3 days course called ‘Positive Dementia Care’ training with the Alzheimer society. Other staff will attend a 12 weeks distance learning course to complete the Positive Dementia Care‘. On the day of inspection staff attended an in house training on infection control. St Catherines Rest Home Version 1.10 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) and 38 31,33,35,36 The home has an effective quality monitoring system in place. 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 by 2005. Information regarding financial management of the service users money should be made available for inspection. EVIDENCE: The registered manager was not available at the time of the inspection as she was on her annual leave. However, the registered manager should complete her NVQ level 4 qualifications in management by 2005. In the absence of the registered manager there is a deputy house manager. The Deputy is currently undertaking Registered Manager’s Award qualifications. St Catherines Rest Home Version 1.10 Page 18 The home carry out service users/relatives satisfaction survey on a three monthly basis. ‘Cared for Quality Assurance’ system is in place, which measure success in meeting the stated aims, objectives and statement of purpose of the home. The results of the survey was published and made available for all relevant parties. The Inspector was not fully able to assess Standard 35, as the deputy manager did not have information available at the time of the inspection. However, she mentioned that the proprietor deals with some of the service users finances and family and Power of Attorney manage others. Staff interviewed confirmed that they receive a minimum of six individual supervisions by their line managers. Notes of the supervision were available for inspection. A regular staff meeting takes place and minutes were available at the time of the inspection. 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 The management ensures service users and staff health, safety and welfare. Staff attended moving and handling, fire safety, first aid, food hygiene and elder abuse training. Regular checks are carried out on gas and electric appliances. The home has a valid insurance cover against loss or damage to the assets of the business. St Catherines Rest Home Version 1.10 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 x 3 x 2 x x 3 St Catherines Rest Home Version 1.10 Page 20 NO Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13 Requirement The management must ensure that staff record all medication administrations on MAR sheets immediately after administration of medications. The registered manager to complete her NVQ level 4 qualifications in management by 2005. Timescale for action 31/10/05 2 OP31 9 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP29 OP35 OP27 Good Practice Recommendations It is recommended that information regarding staff recruitment and relevant checks are available for inspection. It is recommended that information regarding the management of service users finances are available for inspection. It is recommended that the management should review staffing level from time to time in order to meet service users assessed needs. St Catherines Rest Home Version 1.10 Page 21 Commission for Social Care Inspection Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Rest Home Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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