Inspection on 01/06/06 for St Katherine`s

This inspection was carried out on 1st June 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 Katherine`s 29/04/08

St Katherine`s 01/05/07

St Katherine`s 08/12/05

St Katherine`s 12/09/05

St Katherine`s 14/03/05

St Katherine`s 18/11/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Katherine`s 89 Shaftesbury Avenue Leeds West Yorkshire LS8 1DR Lead Inspector Catherine Paling Key Unannounced Inspection 1st June 2006 09:30 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 Katherine`s DS0000001499.V296106.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 Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Katherine`s Address 89 Shaftesbury Avenue Leeds West Yorkshire LS8 1DR 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) 0113 269 7797 0113 2697807 St Katherine`s (Leeds) Limited Mrs Catherine Horner Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: St Katherines provides care, without nursing, to 18 people of both sexes, over the age of 65. The home is located in a peaceful residential area, close to Roundhay Park and Canal Gardens. Shops, pubs, churches, coffee shops and restaurants are all close by and the home is within easy reach of bus stops. There are four floors, three of which are used by residents. The office, laundry, storage rooms and staff room are all on the lower ground floor. Accommodation for residents is in a combination of single and shared rooms, some of which have an en-suite toilet. The ground floor has a lounge and dining room, there are outdoor areas at each side of the home, and there is a small car park for approximately eight cars. The provider has information for prospective residents in the form of a Statement of Purpose, Service User Guide and brochure. These documents together reflect the service provided. As of June 2006 the fees range from £375 to £400. Additional charges are made for dry cleaning, hairdressing and telephone calls. If staff are required to escort residents on out-patients appointments to hospital or for any other appointments a charge of £15 will be made plus any taxis fares. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out between 09.30 and 16.00 by two inspectors. The people who live in the home prefer the term resident therefore this is the term that will be used throughout this report. The registered manager/provider, Mrs Horner, was available throughout the day together with the deputy manager to answer questions, supply records and other information. Before the inspection accumulated evidence about the home was reviewed. This included looking at the number of reported incidents and accidents, the action plan submitted following the previous inspection and reports from other agencies i.e. the fire safety officer’s report. This information was used to plan the inspection visit. During the inspection, records were looked at, care staff were observed carrying out their work, and a tour was made of some parts of the building. Residents, staff, visitors and the manager were spoken with throughout the day. A total of four residents were case tracked. Case tracking is the method used to assess whether residents receive good quality care that meets their individual needs. The twenty-two key standards from the Care Homes for Older People National Minimum Standards were assessed as well as other relevant standards. Comment cards/questionnaires were left for residents and visitors. Comment cards were also sent to other health care professionals following the inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). Any comments received would be discussed with the manager, without revealing the source. At the time of writing the report three have been returned from visiting healthcare professionals all indicated that they were satisfied with the way they were received at the home and that staff carry out their instructions reliably. We would like to thank everyone who took the time to talk with us and shared their views during the visit. Feedback was given to Mrs Horner and her staff team following the inspection. Copies of previous inspection reports are available via the Internet at www.csci.org.uk. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There has been little progress in addressing the shortfalls in the residents’ records. There must be clear evidence that a thorough pre-admission assessment has taken place, and that all the relevant people are consulted before any decisions regarding admission are made. Care plans must give clear and detailed information for staff about all aspects of the resident’s care. They must be updated as and when needs change and must be reviewed at least once a month. Risk assessments must be completed for all areas of risk and care plans developed to address any identified risks. The manager and St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 7 her staff have discussed these shortfalls with a view to introducing an alternative recording system. The staff personal recruitment files did not clearly demonstrate robust selection and recruitment. The manager had already identified the shortfalls in these files. The planned action to address the shortfalls should be implemented as soon as possible to make sure that all staff have had the required pre-employment checks. Staff were still using the kitchen entrance to access and exit the home this must cease. Pets must not be allowed in the kitchen. Staff must follow safe moving and handling procedures when transferring people in wheelchairs. The refurbishment work must continue at the home to make sure that the residents live in a safe and well-maintained environment. A full list of requirements and recommendations can be found at the end of this report. 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 Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. (Standard 6 is not applicable to this service) Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with enough information to enable them to make an informed decision about moving into the home. The admission processes do not always provide evidence that residents needs can be met at the home. EVIDENCE: The provider has reviewed the Statement of Purpose, Service User Guide and also has a brochure to provide information for prospective residents. These documents together reflect the service provided and would enable an informed choice to be made about moving into the home. Visits to the home are encouraged and do take place for prospective residents. Records indicated that one resident had visited the home before she was admitted and joined other residents for a meal before making her mind up to move in. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 10 The records of four residents were looked at during the inspection. Preadmission assessments were not included in all cases. One pre-admission assessment was seen which was undated and unsigned. This assessment included very good detailed information regarding the needs of the prospective resident and the suitability of the placement. All new service users must have a detailed assessment available to determine that their needs can be met at the home. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not give clear and detailed information for staff providing the opportunity for care needs to be overlooked. Residents’ privacy and dignity is respected. Overall medication practices are safe although some practices provide the opportunity for potential error. EVIDENCE: The records of four residents were looked at as part of case tracking. The records contained basic assessment information, personal details, health care needs, risk assessments and care plans. There were both short and long term care plans although these documents were not used effectively and did not provide clear detail of what intervention was needed in order to meet care needs. Although a falls risk assessment was seen for one resident who was at high risk of falling there was no care plan to address this risk and it had not been St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 12 reviewed following a serious fall which had resulted in hospital admission. The changing needs of this resident following discharge from hospital were not reflected in the records although staff fully understood and were responding to her increased dependency. Nutritional risk assessments were not seen. One care plan had been written providing clear instructions for staff to meet the psychological needs of one resident; unfortunately it had not been evaluated or updated. Staff must also remember the importance of dating and signing in full all documented information. During the inspection the home was visited by the district nursing service. The district nurse said that she found the staff to be very helpful and able to carry out any instruction to provide health care treatment and monitoring. The staff kept her well informed of service user progress or deterioration. The staff were observed treating residents with respect and maintaining privacy. Residents are free to use their bedrooms as and when they wish and lockable facilities are provided. Residents confirmed that staff are aware of the need to maintain dignity and personal care tasks were carried out in a professional manner. All the care staff involved in giving medication have received training. There are policies and procedures to support the staff. However, it was established that one resident was receiving oxygen therapy that was not written on the medicine administration record (MAR). In addition, there was no policy for staff to refer to and they had not all received training in the administration of oxygen. The provider agreed to pursue this with the relevant GP. A dedicated fridge has been provided for drugs requiring cold storage. It is not lockable but is kept in a locked room. It was recommended that the temperature be checked occasionally to make sure that it is efficient. The homely remedies provision has been reviewed with the GPs serving the home. However, it was noted that there were some inconsistencies between two lists of homely remedies available at the home. In addition, items included on the list must be specific, for example a specific cough mixture should be noted and not just ‘cough mixture’. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff and resources are provided to allow for activities and stimulation. Residents are able to make decisions about their lifestyle and maintain good contact with family, relatives and friends. EVIDENCE: Following discussions with residents it was evident that they have the opportunity to maintain a high degree of control of their daily lives. Residents said they could get up when they wish and choose what time they go to bed. A very good range of activities are offered at the home. An activity organiser visits the home three times a week. He organises quizzes, sing a longs and bingo. The residents really look forward to his visits and very positive comments about the sessions were made to the inspector. A number of visitors were present during the inspection, again very positive feedback was provided comments like “ the staff are very helpful and friendly” St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 14 And, “ the care is brilliant, the meals are very good and the entertainment is excellent”. Visitors also felt they were made to feel welcome at the home and were kept up to date with any changes to their relatives care and any illness or accidents. One of the inspectors joined the residents for lunch. A three-course meal was provided including soup, main course and sweet. The meal was well presented and was of a good quality. Residents were consulted regarding portion size and were offered a choice. The tables were very well presented with fresh fruit available on each. The staff were on hand to provide assistance as required. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The level of staff understanding gives assurance that complaints will be taken seriously and residents will be protected from abuse. EVIDENCE: A log of complaints is now kept at the home. The majority of the complaints are of a minor nature and some of the information seen in this log should have been recorded in individual resident records. There is a complaints procedure that is made available to residents. One resident said he knew who to complain to and that he had a leaflet giving him guidance should he need it. Residents said that they felt they would be listened to and that any concerns or complaints would be dealt with promptly. There is an in-house procedure about adult protection and the local authority multi agency procedures for the protection of vulnerable adults is available to staff. Some staff including the deputy manager have received training in adult protection. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a safe and reasonably well-maintained environment with refurbishment and redecoration being addressed. EVIDENCE: A full tour of the premises was not undertaken during this inspection. However a number of bedrooms were seen during conversations with residents and visitors. The outstanding requirements and recommendations from the last inspection were updated. The provider is making progress with the updating of the premises. The dinning area and ground floor corridor, stairs and laundry have been refurbished. Resident bedrooms are being up graded as they become empty. The majority of the requirements and recommendations have now been completed or are in the process of completion. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 17 The home is comfortable and is kept clean and tidy. The kitchen was hygienic and was well organised; however it is still being used as a thoroughfare for staff and the home’s cat. This must be addressed. There is some work outstanding including: • • • • • • • poor hot water pressure in one room curtain tracking is required in one room to provide privacy in a double room a bedroom door lock was missing and must be replaced all radiators must be guarded all wardrobes must be secured window restrictors must be fitted to all windows a fly net is required to the kitchen door. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Overall the numbers of staff on duty are adequate for the needs of the residents. Staff are well trained and knowledgeable about the needs of the residents. The homes current recruitment practices need to be reviewed to make sure that new staff are thoroughly vetted to protect residents. EVIDENCE: There is a stable and constant staff group at the home providing continuity and consistency for residents. The manager continues to keep staffing levels under review to make sure that there are sufficient staff to care for the residents. On the day of the visit the manager was carrying out cooking duties as the chef was on leave. There is one waking night care staff and one person who is ‘on-call’ in the building. Arrangements have been made since the last inspection by means of the provision of ‘walkie talkies’ to ensure that staff sleeping or working in the basement laundry can be called promptly. There is a training programme in place at the home to ensure that staff are updated in mandatory training. On the day of the visit training in manual handling techniques was being provided to staff by an accredited trainer. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 19 In addition the manager provides training in a variety of other topics to make sure that staff are equipped to carry out their caring role. The home has achieved the 2005 target of 50 of the care team having completed National Vocational Qualification (NVQ) at level two or above. The recruitment files of two recently appointed care staff were looked at. Shortfalls were identified which were shared with the manager. The manager acknowledged that the files were not up to date and she already had plans in place to address the issues as required under the Care Homes Regulations. Care must be taken to make sure that appropriate references are sought for all employees and that full job histories are explored with applicants. The manager was utilising the POVA First (Protection of Vulnerable Adults) checks and following these up with full checks by the Criminal Records Bureau. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is reasonably well organised and the staff contribute to the decision making process. The interests of the residents are seen as very important to the manager and her staff and are safeguarded at all times. EVIDENCE: The manager is experienced in the care of older people, and although she undertakes training to update her skills, she does not intend to pursue an NVQ (National Vocational Qualification) in Care or the Registered Manager’s Award (RMA). Instead, she is supporting her deputy through both awards in the hope that she will eventually apply for registration with the CSCI (Commission for Social Care Inspection). The deputy manager was due to complete her NVQ St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 21 level 4 in care. The manager was hoping that she would then commence the RMA later this year. The systems in place for monitoring the quality of the service are largely informal. The manager meets with the residents daily and regularly sees the relatives. Following the previous inspection the manager invited relatives into the home and provided feedback from the inspection visit. The manager said that she has offered the option of a questionnaire to relatives and other stakeholders but it was not felt necessary, as she is highly visible in the home and accessible to both relatives and residents. Staff meetings are held and there are good communication systems with a detailed handover between shifts held every day. Feedback following this inspection was also shared openly with all staff. Records are kept of all accidents in a book and on specific forms. It was suggested that the manager review the method of recording accidents as staff are currently having to record the information in several places. Consequently the standard of recording was variable with some information missing, such as the time a resident was last seen before an unwitnessed accident and the signatures of the person completing the record. Some residents were seen being transported in wheel chairs without footplates in place. This means that residents have to hold their feet up putting strain on their cardiovascular system. Footplates must always be used unless the reason not to is clearly documented in the individual records. The vast majority of the work identified in the fire safety officer’s report of January 2006 and been actioned. St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 22 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 3 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 2 2 X 2 X X 2 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X X 2 St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 (1)17 (3) (a) Requirement Care plans must set out in detail the action that needs to be taken by staff to make sure that all aspects of the health, personal and social care needs of the resident are met. The plan must be drawn up with the involvement of the resident, recorded in a style accessible to the resident, and agreed and signed by the resident and/or his/her representative wherever possible. The care plan must be reviewed by staff at least once a month and must be updated to reflect changing needs. This is unmet from 16/11/04, 14/03/05, 12/09/05 & 31/03/06. Where residents are identified as being at risk, a plan to manage the risk must be developed. This is unmet from 12/09/05 & 31/03/06 St Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 24 Timescale for action 04/12/06 2. OP18 13 (6) The homes policy on adult abuse 01/09/06 must refer staff to the Multi Agency Adult Protection Procedures. This is unmet from 12/09/05 & 31/01/06. The programme of decoration and refurbishment must continue. The call system must be replaced by one that is cancelled at the point of actuation. All pipe work and radiators must be guarded or have guaranteed low temperature surfaces. This is unmet from 16/11/04, 14/03/05, 12/09/05 & 31/03/06. Staffing levels must be kept under review to make sure that there are sufficient staff on duty at all times. 3. 4. 5. OP19 OP22 OP25 23 (2) (b) 23 (2) (c) 13 (4) (a) 04/12/06 04/12/06 01/09/06 6. OP27 18 (1) (a) 04/12/06 7. OP38 13 (4) (a) All people working in the home must be clearly identified on the rota. Window restrictors must be fitted 04/12/06 on all windows. This is unmet from 16/11/04, 14/03/05, 12/09/05 & 31/01/06. Nutritional and falls risk 01/09/06 assessments must be completed. This is unmet from 01/01/06. Fly nets must be fitted to the door in the kitchen. This is unmet from 01/01/06 Staff and visitors must not enter or leave the home through the kitchen. This is unmet from 08/12/06 Pets must not be allowed in the kitchen. This is unmet from 08/12/06 DS0000001499.V296106.R01.S.doc 8. OP8 13 (4) (c) 9. OP38 13 (3) 01/09/06 10. OP38 13 (3) 02/06/06 11. OP38 13 (3) 02/06/06 St Katherine`s Version 5.2 Page 25 12. OP38 13 (4) (c) Footplates must be fitted to wheelchairs when transferring residents, unless the reason for not doing so is explained in the person’s care plan. This is unmet from 08/12/06 02/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The home’s pre-admission assessment information should include a detailed summary of events leading to admission. The assessment should identify those people consulted during the assessment process, the outcome of the assessment and justification of whether or not the home is able to meet assessed need. The assessment form should be signed and dated by the person conducting the assessment. The medication policies and procedures should in one to cover the administration of oxygen. Staff should be trained to make sure that they properly and safely administer oxygen. The provider should implement plans to review the recruitment files to make sure that there is clear evidence that all the necessary checks have been carried out for employees. Satisfaction questionnaires should be distributed annually. Distribution should include residents, relatives, GPs, District Nurses, Social Workers and other professionals. The results from the questionnaires should be analysed and made available to all those concerned. Policies and procedures should be reviewed to make sure that they reflect current practices in the home. If a resident has an accident that is not witnessed by staff, a record should be kept of when the person was last seen and by whom. DS0000001499.V296106.R01.S.doc Version 5.2 Page 26 2. OP9 3. OP29 4. OP33 5. 6. OP33 OP38 St Katherine`s Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Katherine`s DS0000001499.V296106.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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