Inspection on 29/04/08 for St Katherine`s

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate service.

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 01/05/07

St Katherine`s 01/06/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Katherine`s 89 Shaftesbury Avenue Leeds West Yorkshire LS8 1DR Lead Inspector Catherine Paling Key Unannounced Inspection 29th April 2008 09:15 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.V361927.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.V361927.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 Miss Victoria Robertshaw Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st May 2007 Brief Description of the Service: St Katherines provides personal care only for up to 18 people of both sexes, over the age of 65. The community nursing service provides nursing support. 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 the people living at the home. The office, laundry, storage rooms and staff room are all on the lower ground floor. Access to the upper floors is by passenger lift. Accommodation is provided in a combination of single and shared rooms, all of which have en-suite facilities. The ground floor has a lounge and dining room. There is a garden that is accessible to the people who live at the home, and 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 an informative brochure. These documents together reflect the service provided. The current fees range from £380 to £412 with additional charges made for chiropody, dry cleaning, hairdressing, newspapers and toiletries. 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. The manager provided this information at the April 2008 inspection. The home should be contacted directly for up to date information about fees. St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit by one inspector who was at the home from 09:15 until 16:45 on 29th April 2008. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. Survey forms were sent out to the home before the inspection providing the opportunity for people to comment on the service, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A small number of surveys were returned by people living at the home, their relatives and staff. Their comments are included in the report. What the service does well: There is a stable management and staff team providing continuity for the people who live at the home. We saw the staff demonstrate patience and kindness to the people they care for. People said: • ‘The carers are pleasant, understanding and helpful towards my mother. This gives her a sense of confidence in them’. All the staff are very knowledgeable about the needs of people at the home and involve other healthcare professionals for advice and support when needed. St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 6 Although there is a limited choice at mealtimes the food served is of a good quality and people enjoy their mealtimes, eating at their own pace. People said: • ‘The meals are nicely prepared and presented’ There is a weekly activities programme and people at the home are encouraged to join in. People said: • ‘I am very happy and comfortable here’. What has improved since the last inspection? What they could do better: The work on the care records needs to continue so that staff are provided with enough information to make sure that care needs are not overlooked. The nutritional risk assessment tool must be introduced for everybody living at the home. This is so that people at nutritional risk are identified and receive the support they need. All the staff must have training in safeguarding so that people know that they are safe and staff understand their responsibilities and how to recognise safeguarding issues. The current staffing arrangements must be reviewed to make sure that there are sufficient staff on duty at all times of the day and night to meet the needs St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 7 of the people living at the home. The suitability of only having one waking night staff must be re-considered in the light of people’s dependency, the layout of the building and fire safety arrangements. Redecoration and refurbishment work should continue to make sure that people live in a comfortable and safe environment. Requirements and recommendations appear at the end of the 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. The summary of this inspection report can be made available in other formats on request. St Katherine`s DS0000001499.V361927.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.V361927.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. (Standard 6 does not apply to this service) People who use the service experience adequate quality outcomes in this area. The home makes sure that they have information about people’s needs before they are admitted to the home. The written information available to people and their families gives them the information they need to decide if they want to move into the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that: All residents are assessed at home or in hospital before admission and that trial visits encouraged. The admission process has been improved with the revision of the Statement of Purpose, Residents Guide and a re-designed St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 10 brochure. The home recognises a need to try to get full details of any medical conditions. The new registered manager has revised the Statement of Purpose and Resident Guide to make sure that people have access to up to date information about the service to help them decide if they want to move in. All the individual records that were looked at had a range of detailed preadmission information. This included local authority assessments and information from other establishments. The home does have their own assessment documentation but in the sample we looked at it was not fully completed. As we found at the last visit pre-admission information in one file indicated that the person had mental health problems for which the home is not registered and the staff are not trained to deal with. The manager now has support from the community psychiatric services and was in the process of considering whether this placement was suitable in the long term. The manager agreed to review the assessment documentation in use and consider the addition of an assessment tool that could help identify mental health issues so that a fully informed decision could be made about whether the home could or could not meet care needs. St Katherine`s DS0000001499.V361927.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. Overall, people’s health and personal care needs are met but because care records do not always reflect this there is always the risk of needs being overlooked. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that: Care plans are in place for everyone and are completed three times each day. The manager is looking at developing ‘end of life’ plans. Hairdressing is provided weekly and chiropody six weekly. Care staff give out medication. Staff respect people’s privacy and dignity at all times. Over the last twelve months staff have continued to strive to include more detail within records. St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 12 We looked at the records of three people. It was clear that work has continued to develop records. Every person who lives at the home has an individual file, which is divided into sections with a clear index to help access to the information. All the files contained clear photographs and a physical description; next of kin contact details together with contact names and numbers of other healthcare professionals involved in the person’s care were clearly presented. Sections in the records contained records of actions taken, for example there was a chart where codes were filled in on a daily basis to indicate how personal hygiene had been addressed that day. However, care plans still need to be produced to indicate personal preferences and what support is required from staff. For example, whether the person prefers a bath morning or night, how often, whether they like a daily shave and detail of how much help they need from staff. The records provide a good foundation but staff now need to make sure personal needs and preferences are clear so that care needs are not overlooked. The daily records are informative and give some detail of changes and care needs. This information should be included on care plans to make sure that staff have easy access to the information they need to effectively care for the people at the home. There are policies and procedures to support the staff in the management of medication and these are easily accessible to the care staff. The local pharmacist provides a good service to the home and this includes training. All the staff involved in the administration of medication had training at the end of 2007. Information from the training programme is also available to staff for reference. Staff know the people who live at the home very well and treat them with respect and patience. However, from discussion with some staff it was clear that they did not always understand people’s behaviour in relation to mental health issues. The manager must now make sure that there is a care plan in place for people when they are admitted to the home. Without this there is no sure way of knowing that staff have accurate information on how to meet people’s needs. Nutritional assessments and falls assessments must be completed when people are admitted to help identify those people who may be at risk in these areas. These assessments should be reviewed as and when needs change. Where a risk is identified a plan must be put in place showing staff the actions they must take to reduce the risk. St Katherine`s DS0000001499.V361927.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 People who use the service experience good quality outcomes in this area. The people at the home are able to make decisions about their lifestyle and maintain good contact with family, relatives and friends. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that: Contact with family is encouraged and visitors are welcomed. Entertainment/activities is provided four times a week and includes singing, quizzes, bingo, games and exercises. Home cooked meals and snacks are available. Any dietary restrictions and preferences are catered for. Systems in place work well and people are happy. People said: • ‘The carers are pleasant and understanding and helpful towards my mother. This gives her a sense of confidence in them’. • ‘The meals are nicely prepared and presented’ • ‘I am very happy and comfortable here’. St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 14 We found from observation and discussion with the people who live at the home that they are encouraged to maintain choice and control over their daily lives. People said they could get up when they wish and choose what time they go to bed. There are regular activities organised at the home. An activity organiser visits the home three times a week and organises quizzes, sing a longs and bingo. The people at the home really look forward to his visits. The hairdresser visits the home weekly. She has a good rapport with the people at the home and people clearly enjoy her visits. Some people go out with their friends and family, staff take others out. One person told us about a recent visit to a local pub and another person told us about a recent weekend stay with family. Visitors are made welcome at the home. The chef is aware of people’s likes and dislikes and produces a varied menu for the people at the home. The lunchtime meal is three-courses including soup, a main course and sweet. There is limited menu choice but alternatives are provided if necessary. We saw people enjoying their food in a relaxed and unhurried way with everyone encouraged to eat at their own pace. We saw brief records of activities people have enjoyed but there was not a lot of information of how people at the home like to spend their leisure time and what hobbies they might still be able to enjoy. There are currently three people living at the home who do not have English as their first language. Any specific cultural and religious needs and beliefs must not be overlooked. St Katherine`s DS0000001499.V361927.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 and 18 People who use the service experience adequate quality outcomes in this area. People living at the home can feel that their views are listened to and taken seriously. The lack of safeguarding training for staff could put people at potential risk. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that: There is a complaints procedure in every room and in the Statement of Purpose. Any complaints are recorded in the complaints book. There was one complaint recorded in the last year. There is a complaints procedure and it is made available to the people who live at the home. Everyone we spoke to said that they knew who to speak to if they had any concerns. People who live at the home are confidant that they would be listened to and that any concerns or complaints would be dealt with promptly. Records are kept of complaints received and there has been one complaint that has been dealt properly following the in-house procedure. St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 16 There is an in-house procedure about adult protection and the local authority multi agency procedures for the protection of vulnerable adults are available to staff. Local contact numbers are included so that staff can be clear about where to seek advice if they had any concerns. However, staff have yet to have training in the safeguarding of vulnerable adults. Staff must have training in this important area and discussion about safeguarding should take place at staff meetings to make sure that everyone is aware of what constitutes safeguarding and what to do if a safeguarding issue is suspected or reported. St Katherine`s DS0000001499.V361927.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 and 26 People who use the service experience adequate quality outcomes in this area. The people at the home live in a safe and well-maintained environment with the necessary refurbishment and redecoration being addressed. Some practices put people at potential risk of cross infection. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that the home provides a: Homely, caring, safe and well maintained environment. All rooms are en-suite with a bathroom on each landing. There is a plan for ongoing re-decoration and maintenance. St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 18 Over the last twelve months the following improvements have been made: • The low sill in the dining room is now protected following Health and Safety advice • Decoration is ongoing • The ground floor bathroom is now a walk-in shower • New flooring provided in the kitchen The provider has continued to make progress with the ongoing redecoration and refurbishment of the building. The home was clean and comfortable and the areas visited were odour free. Bedrooms are comfortable and we saw that people have personalised their rooms with their own belongings. A ground floor bathroom has been altered to take a walk in shower. To make this as accessible as possible a shower seat is needed. The kitchen was clean, tidy and well organised. Although fly nets are fitted to the window it was broken. This has been repaired previously and now should be replaced. The kitchen was awarded a 4* rating by Leeds City Council after the environmental health inspection of November 2006 The laundry area was clean and tidy with two sluice washers and a tumble dryer provided. The practice of throwing soiled towels down the cellar steps should stop in the interest of infection control. The current practice of dealing with foul linen should also be reviewed. The use of soluble red bags should be re-introduced to reduce the handling of foul linen and the risk of cross infection. St Katherine`s DS0000001499.V361927.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 People who use the service experience adequate quality outcomes in this area. Overall the numbers of staff on duty are adequate to meet the needs of the people living at the home. Staff are well trained and knowledgeable about the needs of the people at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that: All but three of the care staff have NVQ 2 and three staff have NVQ 3. There is a low turnover of staff and good staff retention. There is a system of staff supervision and staff appraisal in place. People said: • ‘Everyone works well together, something needs doing and we do it’. • ‘Take care of our residents well with all the different needs that they have’ There continues to be a stable staff group at the home with little staff turnover providing stability and continuity for people living at the home. Overall there St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 20 are enough care staff available on the day shift and they are supported by domestic and catering staff. However, the number of care staff reduces at the weekend and there is less ancillary support at the weekend. This reduction in staffing at the weekend must be kept under review. There continues to be one waking night care staff with one carer sleeping on an ‘on-call’ basis in the building. There are arrangements in place to make sure that the on-call member of staff can be contacted promptly if necessary. The suitability of only having one waking member of night staff must be kept under review, taking into account the layout of the building and the current dependency levels of the people at the home and the fact that night staff have a responsibility for doing the laundry at night. There is no annual training plan apart from mandatory training. Training priorities were discussed with the manager and should include safeguarding and dementia care. The manager also needs to address, through training, staff understanding of the care needs of people with mental health needs. The manager also intends to develop a training matrix to allow her easy access to individual training information to make sure that training is up to date for staff. The majority of the care team have completed a National Vocational Qualification (NVQ) at level 2 in care with three staff having the qualification at level 3. We looked at the recruitment files of recently employed staff and found there are sound recruitment procedures in place with all the necessary checks completed before people start work at the home. St Katherine`s DS0000001499.V361927.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, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. The new manager has provided stability at the home as well as clear direction and leadership to make sure that the home is run in the best interests of the people living there. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA stated that: All senior carers and carers are able to manage the home in the absence of the manager. There are plans to review risk assessments, policies and St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 22 procedures. Staff meetings continue to take place on a regular basis. Meetings with people living at the home and their relatives are not held regularly due to a lack of interest – but the manager has ‘informal chats’ on a daily basis with people and they feel ‘more at ease this way’. There has been a change of registered manager since the last inspection with the deputy manager having completed the process to become registered as manager of the home. She has completed an NVQ in care at level 4 and is currently working towards the Registered Manager’s Award (RMA). She has worked at the home for a number of years before becoming manager and so there is continuity for people living there. The systems in place for monitoring the quality of the service are largely informal with the manager being able to see the people living there and their relatives on a reasonably regular basis. Meetings are not held regularly as people have shown little interest in them up to now. The quality audit tool started in March 2007 has not been completed. The manager needs to develop quality systems so that she can provide evidence of how she monitors the service and facilities and how she makes sure that all parties are kept informed of changes and developments. Staff meetings are held on an ‘ad hoc’ basis when there are important issues to be discussed with all staff. Otherwise this small stable staff team see each other regularly during shifts or at shift changes. The manager has reviewed all the policies and procedures since taking over to make sure that staff have clear and up to date information about work practices. Clear records are kept of accidents occurring at the home. We discussed with the manager ways of using this information to monitor the frequency and timings of accidents to help identify any trends or issues. The home do not act as appointee but helps a number of people manage their personal allowance. Clear records were kept and receipts were also available. St Katherine`s DS0000001499.V361927.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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 24 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 Requirement All the people using the service must have a detailed care plan that gives staff clear instructions on how to deliver care. This will ensure that people receive care that meets their individual needs. Timescale for action 06/10/08 2. OP8 13 (4) (c) Timescale of 21/12/07 not met 08/09/08 All the people using the service must have their nutritional needs assessed. If a person is identified as being at nutritional risk than a plan of management must be in place to make sure that people receive the nutritional support they need. Timescale of 01/10/07 not met Arrangements must be made for all staff to have training in adult safeguarding as soon as possible to make sure that all people living at the home are safe. The current arrangements for one waking and one sleeping DS0000001499.V361927.R01.S.doc 3. OP18 13(6) 24/11/08 4. OP27 18(1)(a) 11/08/08 St Katherine`s Version 5.2 Page 25 night staff must be reviewed, taking into account the dependency levels of the people at the home and the layout of the building and fire safety arrangements. 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 4 Refer to Standard OP3 OP19 OP26 OP27 Good Practice Recommendations The manager should work at developing the homes own pre-admission assessment information to make sure that they are fully aware of the individual care needs. The provider should continue with the refurbishment of the home to make sure that people live in a safe and comfortable environment. Infection control practices should be reviewed to make sure that people are not put at risk of cross infection. The care staffing levels should be kept under review to make sure that there are enough staff to meet the needs of the people living at the home. This is with particular reference to the reduction in care staffing levels at the weekend when there is reduced ancillary support for carers. Arrangements should be made for staff to have training in mental health topics such as dementia care, to help them have a better understanding of the care needs of some of the people at the home. There should be a formal system in place to demonstrate how the services and facilities are monitored to make sure that people get a good service and are cared for properly. 5 OP30 6 OP33 St Katherine`s DS0000001499.V361927.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI St Katherine`s DS0000001499.V361927.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. Re-publishing this information is in breach of the terms of use of that website. 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