Inspection on 08/12/05 for St Katherine`s

This inspection was carried out on 8th December 2005.

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 01/06/06

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 Ann Stoner Unannounced Inspection 8th December 2005 9.30 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.V271512.R01.S.doc Version 5.0 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.V271512.R01.S.doc Version 5.0 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.V271512.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 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. 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 double 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. Shops, pubs, churches, coffee shops and restaurants are all close by and the home is within easy reach of bus stops. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 12th September 2005. There have been no further visits until this unannounced inspection. This inspection was carried out between the hours of 9.30am and 5.30pm, 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. During the inspection, we looked at records, saw care staff carrying out their work, made a tour of some parts of the building and spoke with residents, staff, visitors and the manager. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). We discuss any comments received with the manager, without revealing the identity of those completing them. None have been returned. Copies of previous inspection reports are available via the Internet at www.csci.org.uk. What the service does well: What has improved since the last inspection? The manager is showing a willingness to work with the CSCI (Commission for Social Care Inspection), and although much more work is needed to meet the National Minimum Standards, improvements are now noticeable. All staff have completed training in moving and handling, first aid and food hygiene. Future planned training events include adult abuse, adult protection and care of people with diabetes. Changes to the environment are slowly taking place. Windows on the top floor have been replaced and if the planned programme goes according to schedule all windows will be replaced by the end of January 2006. Door guards are being fitted to eliminate the need for doors to be propped open with wooden wedges. Work is in place to fit intumescent strips as recommended by the Fire Officer. The dining room has recently been decorated. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 6 Improvements to paper work include amendments to the Statement of Purpose, a training and development plan and an improved assessment format. What they could do better: The home should make sure that a thorough pre-admission assessment takes 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. Staff must not use abbreviations when writing in care plans or other records. Risk assessments must be completed for all areas of risk. The home must develop a safe system for using homely remedies. A record must be kept of the date when medication with a short life span, such as eye drops, are put into use. Medication needing cold storage must be stored in a refrigerator. Bottles of medicine should be cleaned after use, and the medication trolley should be cleaned on a regular basis. Formal menu planning should be introduced and menus should be rotated over a planned cycle. Glass tumblers should replace the plastic beakers currently in use. All complaints, however small, must be recorded along with the outcome of the complaint. The policy on adult abuse must be amended. Door wedges must not be used to prop open doors, equipment must not be stored at the bottom of the staircase, archived records must not be stored in an open cupboard on a stairwell, and ‘Keep Locked’ signs must be fitted on laundry doors. All doors must be checked to make sure that they close properly. Suitable locks must be fitted on all bedroom doors. Stained pillows must be replaced in one person’s room, bedside lights must be provided in all rooms, and the call alarm system must be within easy reach of residents when they are in bed. Liquid soap and paper towels must be provided in all areas where care is given and clinical waste is handled. Refurbishment must continue, and all radiators must be guarded. The laundry room must be kept clean and tidy. Staffing levels must be kept under constant review, and night care practices, such as washing and ironing in the basement, where it is difficult to hear the call system must be addressed. Satisfaction questionnaires must be distributed annually, and the results from questionnaires should be analysed and published. Policies and procedures should be reviewed to make sure that they reflect current practices within the home. The home must notify the CSCI of all significant events as required by regulation 37. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 7 Staff and visitors must not use the kitchen entrance to access and exit the home. Pets must not be allowed in the kitchen. Kitchen practices must be reviewed to make sure that the kitchen is clean at all times and that good food hygiene is consistently followed. Staff must follow safe moving and handling procedures when transferring people in wheelchairs. Where staff do not witness accidents, a record should be kept of when the person was last seen and by whom. A number of requirements and recommendations have been made to address these issues, some of which require immediate action. An immediate requirement letter has been sent to the home. 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.V271512.R01.S.doc Version 5.0 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.V271512.R01.S.doc Version 5.0 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. Standard 6 does not apply to this home. There is now some information available for future residents to allow them to make their decision about admission. Resident’s needs are assessed before they move into the home, but from the information recorded it is not clear how the home is able to meet the person’s needs. EVIDENCE: The home has a statement of purpose, and although some amendments have been made, further work is needed so that this document meets all of the requirements stated in Schedule 1 of the Care Homes Regulations 2001. There is still no service user guide, but the manager was able to explain how she is developing a brochure about the home, which will incorporate the service user guide. Improvements have been made to the way that the home carries out and records pre-admission assessment information, but additional work should take place to make sure that the home is able to meet assessed need. The preadmission information was sampled for a resident recently admitted to the home. Although there was some good information recorded such as, details St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 10 about the specific amount of assistance required with personal care and the person’s need for snacks during the afternoon, there was no exploration of comments made in a letter by a Consultant Psychiatrist, stating that the person had ‘moderately severe dementia’. This person had been admitted to hospital with a fractured pubic bone. There was no information in the assessment about how this happened, no information about any previous falls, no information about why the person was not discharged back to a previous care home and there was no mental health assessment. The assessment did not clearly identify who was consulted during the process or who supplied the information, and whether or not the home could meet identified need. The assessment was not signed or dated by the person completing the assessment. Requirements and recommendations to address these issues have been made. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 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. Care plans are poor and could lead to needs being overlooked. Some medication practices and policies create the opportunity for mistakes. EVIDENCE: Three care plans were sampled and the results were disappointing. There was no plan of care in place for a resident who was admitted on the 27th October 2005. From information recorded in this person’s daily records it was clear that there were some mental health issues, but there was no information for staff on how to deal with these. This person had a previous history of falls, and had sustained falls in the home but there was no falls risk assessment in place or plan on how to prevent further falls. She had a poor fluid intake, poor appetite and low weight, but there was no nutritional assessment completed. There were instructions from this person’s GP to increase her fluids, but there was no fluid chart in place, and no way of monitoring whether this was in fact actually happening. One person’s care plan stated that he was independent in almost every aspect of his care. However, his daily records stated that he had an accident away from the home affecting his independence. As a result, he needed help to mobilise because he was unsteady on his feet, he needed assistance to use the toilet, to wash and dress, to get in and out of bed, and needed his food liquidised. His care plan had not been updated or amended and there were no instructions for staff on how to deliver this care. There St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 12 were no nutritional or falls risk assessments in place, and no plan on the prevention of further falls. This person was a diabetic controlled by tablets. Staff monitor his blood sugar levels on a daily basis, but there was no care plan in place giving staff clear instructions about acceptable levels of blood sugar, and what they should do if his blood sugar levels became too high or too low. Similar information was missing from another person’s care plan who had diabetes controlled by insulin. There was no evidence that the resident and/or his or her representative had been consulted or agreed with their plan of care, and it was difficult to tell if the care plans had been evaluated or reviewed. Staff use abbreviations in records, such as A.T.O.R. (at time of report). The home’s system for using homely remedies is unclear, and the full list of remedies used by the home has not been agreed by GPs. Records were seen of homely remedies being used in the home; these were not dated and not recorded on the person’s medication administration record (MAR). Eye drops, which should be discarded after one month, were in use. There was no record made of the date when these eye drops were opened. The home keeps a record of medication returned to the pharmacist, but there was no date recorded on the last items returned. Medication needing cold storage is stored in the kitchen fridge, however some medication, that needed cold storage, was seen in the medical room. Bottles of medicines are not cleaned after use, and the medication trolley needed cleaning A number of requirements and recommendations have been made to address these issues. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 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): 14 & 15. Some choices are available to residents, and a wholesome diet is provided. EVIDENCE: Residents are able to choose what time they go to bed and what time they get up in the morning. A varied diet is provided and residents were seen enjoying parsnip soup, lasagne, chips, peas and apple crumble and custard. The chef works from 8.45am –2.45pm 5 days a week. Care staff prepare breakfast, and most evenings the manager prepares the evening meal. The home does not provide a cooked breakfast. Menus are not planned and rotated on a three or four week cycle, and the meals provided are not always recorded. Although a choice of the main meal is not available, the chef said that he would make an alternative meal if he knew a resident disliked a particular dish. There is a choice of a hot or cold meal at teatime. Residents at both the breakfast and lunchtime meal ate in a relaxed environment and staff worked at the pace and level of individual residents offering assistance when needed. Glass tumblers would be more appropriate than the plastic beakers currently in use. Recommendations have been made to address these issues. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complaints are not recorded properly and senior staff are not aware of the correct procedure to follow when dealing with abuse. This means that some complaints may not be taken seriously and allegations of abuse may not be dealt with properly. EVIDENCE: From discussions with the manager and senior staff it is clear that there is some misunderstanding about what constitutes a complaint. Minor complaints and grumbles are not recorded. It is therefore impossible to carry out an audit on the number of complaints received. The home’s policy on adult abuse has been amended, but this document must be amended further to make sure that staff are informed that if abuse is suspected or reported they must take advice from the adult protection team before any investigation in the home is initiated. The home now has a copy of the Multi Agency Adult Protection Procedures, and senior staff are to attend training on the use of these procedures. Requirements have been made to address these issues. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Some refurbishment work has taken place, and a planned programme is ongoing. This must continue to make sure residents live in a safe environment. Infection control is not properly managed. EVIDENCE: During the inspection a handyperson was fitting door guards to eliminate the use of door wedges, however a number of door wedges were seen propping open doors in various rooms. The handyperson was also fitting smoke detectors and intumescent strips as identified in the fire officer’s report. Windows on the first floor have been replaced, and there is a programme in place whereby all windows will have been replaced by the end of January 2006. The dining room has been decorated, and the colour of the paint for the lounge was being discussed during the inspection. Some work relating to fire prevention still remains outstanding. This includes equipment stored at the bottom of a staircase, which causes an obstruction, archive records stored in an open cupboard on a staircase, and there is no ‘Keep Locked’ sign on linen St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 16 cupboard doors. The manager said she would be using the consultancy services of an ex-fireman in the New Year. One bathroom door and a fire door in the front entrance did not close properly. Yale locks are fitted on bedroom doors; one was seen immobilised by a nail preventing the lock being used. Bed linen was very thin in one room and the pattern of the mattress could be seen through the sheet. One person had very soiled pillows and a torn mattress. Not all rooms have lockable space, and liquid soap and paper towels are not used in all areas where clinical waste is handled. Bedside lights are not provided in all rooms, and in shared rooms there is only one central light. There is a call system in place, but this is cancelled at a central point, and is difficult for staff to hear when working in the basement. Calls leads are not provided in all rooms, and there is no accessible call system at all for some residents. Some areas of the home, particularly staircases and corridors remain shabby and stair carpets are worn and threadbare in some places. Although there is a planned programme in place not all radiators have yet been guarded. The laundry room was dirty. There were cobwebs hanging from the ceiling, there was a layer of dirt on the window ledge, there were holes in the plaster on the walls, there was a container storing soiled linen, the sink was stained and there was no proper hand washing equipment for staff. A number of requirements have been made to address these issues. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 17 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 & 30. Staff receive appropriate training and have achieved the 2005 target for NVQ (National Vocational Qualification), but staffing levels are low. EVIDENCE: The staffing rota is stretched, and the home relies on the manager and her son to undertake cooking duties in the absence of the chef. There is only one domestic who works four hours a day, although the manager said that she employs two other workers on a regular basis when deep cleaning is needed. These people are not shown on the rota. There is one waking night care staff and one person who is ‘on-call’ in the building. In an emergency the waking night staff has to go to the basement to summon assistance from the ‘on call’ person. The manager said that she is looking into a system to address this. In addition to caring duties the night care worker carries out all the laundry and ironing tasks in the home. This is carried out in the basement of the home, where it is difficult to hear the call system. Again the manager said she is looking at ways to address this. This must be a priority. The manager must keep the staffing levels under constant review and balance the staffing levels against the dependency levels and needs of the resident group. Requirements have been made to address these issues. New staff complete an induction based on the TOPSS (Training Organisation for Personal Social Services) standards and the manager and deputy have attended training on the Common Induction Standards that are to be introduced shortly. Staff described the training they have attended in the last twelve months; this has included moving and handling training, first aid and food hygiene. Future training planned includes diabetes and adult abuse. The St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 18 home has achieved the 2005 target of 50 of the care team having completed National Vocational Qualification (NVQ) at level two or above. The manager has developed a training and development plan, and said that she identifies training needs through supervision and the needs of the residents, which is why staff are attending training on diabetes. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 19 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, 37 & 38. The manager is supporting her deputy to meet the requirements and qualifications of the Registered Manager. Some quality assurance measures are in place but these must be developed further so that the views of all concerned are sought and acted upon. Financial recording does not protect residents from the risk of potential financial abuse. All notifiable events are not reported to the Commission for Social Care Inspection. Entering the home through the kitchen along with some food hygiene practices creates a serious risk of infection. Correct moving and handling procedures are not always followed. EVIDENCE: The manager is experienced in the care of older people, and although she undertakes training to update her skills, she has no intention of completing an NVQ (National Vocational Qualification) in Care or the Registered Manager’s St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 20 Award. 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 manager said that residents’ meetings are unnecessary because of the regular discussions held over meal times. An example of this was seen when, after their lunchtime meal, residents were asked for their views on colours for the forthcoming refurbishment of the home. She also said that she speaks to relatives on a weekly basis during their visits to the home. Residents are given a satisfaction questionnaire to complete, but this is given to them soon after admission. It is recommended that this be distributed on an annual basis, and the views of other professionals such as GPs, Social Workers and Community Nurses should be sought. The results from the questionnaires should be analysed, acted upon and made available to those concerned. The policies and procedures in place do not reflect current practices in the home. Residents have full control of their own money. Where pocket money is handed over a record is kept but only one signature is obtained. The home should make sure that a signature is obtained from the person handing over the money and the person receiving the money. The home has a volunteer who carries out shopping on behalf of residents. Receipts and records are not kept of small transactions made on behalf of residents, for items such as birthday cards and sweets. The manager rectified this during the inspection. One resident had an accident whilst on holiday with friends, resulting in injuries affecting his independence. The manager did not complete a Regulation 37 notification in line with the Care Home Regulations 2001. Several concerns relating to hygiene were noted in the kitchen, some of which were rectified by the time this inspection ended. There were no fly nets to the windows or door and the ‘insectocutor’ was not in use. Care staff were seen serving meals and entering the kitchen without wearing protective aprons or tabards. Staff and visitors to the home use the kitchen door as an entrance to the home rather than the main front door. The home has a cat, which was seen going in and out of the kitchen. These practices must cease with immediate effect. Opened food in the fridge was properly wrapped but not dated, and some old vegetables were in the bottom of the fridge. Sterilising wet wipes were placed next to flour, a large jar of mayonnaise, which had been used the previous day, had not been returned to the fridge and there were several opened packets without proper seals. The kitchen door does not have a self-closure device fitted, so it is often left open. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 21 All staff have recently attended moving and handling training, but during the day residents were transferred in wheelchairs without footplates. Someone with first aid training is on duty at all times. The manager said that she keeps an analysis of all accidents, but this is a computer-based record and was not available for inspection. Where a resident has an accident that is not witnessed by staff, the home does not always keep a record of when the person was last seen and by whom. Toiletries were seen in bathrooms, creating a risk of cross infection and providing the opportunity for communal use. Some cleaning materials were seen in one bathroom and the dining room. Window restrictors are not fitted on all windows but the manager said that this would be addressed as replacement windows are fitted. A number of requirements have been made to address these issues. St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 2 2 2 2 2 1 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X 2 1 St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 23 Yes 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 OP1 Regulation 4 (1) Requirement The homes statement of purpose must be amended to cover all items specified in Schedule 1 of the Care Homes Regulations 2001. This is unmet from 21.6.05, and 12.9.05. The home must produce a Service User Guide. Timescale for action 31/03/06 2. OP1 5 (1) 31/03/06 3. OP7 15 (1) 17 (3) (a) This is unmet from 21.6.05 and 12.9.05. Care plans must set out in detail 31/03/06 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 St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 24 and must be updated to reflect changing needs. This is unmet from 16.11.04, 14.3.05 & 12.9.05. Where residents are identified as being at risk, a plan to manage the risk must be developed. 4 5. OP8 OP9 13 (4) (c) 13 (2) This is unmet from 12.9.05. Nutritional and falls risk assessments must be completed. Clear records must be kept of all medication returned to the pharmacist. This must specify the date on which it was returned. All medication requiring cold storage must be stored in a refrigerator. A record must be kept of all complaints, along with the outcome. The homes policy on adult abuse must refer staff to the Multi Agency Adult Protection Procedures. This is unmet from 12.9.05. Work identified in the Fire Officers report must be carried out. This is unmet from 16.11.04, 14.3.05 & 12.9.05. There must be a Keep Locked sign on linen cupboard doors. There must be a smoke seal around the linen cupboard doors. Equipment must not be stored at the bottom of staircases. Archive records must not be stored in an unlocked cupboard on the staircase. DS0000001499.V271512.R01.S.doc 01/01/06 08/12/05 6 7 8 OP9 OP16 OP18 13 (2) 22 (8) 13 (6) 08/12/05 08/12/05 31/01/06 9. OP19 23 (4) (a) 01/01/06 10 OP19 23 (4) (a) 08/12/05 St Katherine`s Version 5.0 Page 25 Wedges must not be used to prop open doors. This is unmet from 16.11.04, 14.3.05, 21.6.05 & 12.9.05. The programme of decoration and refurbishment must continue. All doors must be capable of closing properly. This is unmet from 21.6.05 & 12.9.05. The call system must be replaced by one that is cancelled at the point of actuation. Call leads must be provided in all rooms. The call system must be accessible to all residents when in bed. All residents rooms must have a bedside light provided. This is unmet from 16.11.04, 14.3.05 & 12.9.05. Stained pillows and a torn mattress on one person’s room must be replaced. A review of all bed linen must take place. All residents must have some lockable space in their room. This is unmet from 16.11.04, 14.3.05 & 12.9.05. All bedroom doors must be fitted with locks suited to the resident’s capabilities and accessible to staff in emergencies. This is unmet from 12.9.05. All pipe work and radiators must be guarded or have guaranteed DS0000001499.V271512.R01.S.doc 11 12. OP19 OP21 23 (2) (b) 23 (2) (b) 31/03/06 01/01/06 13. OP22 23 (2) (c) 01/01/06 14. OP24 16 (2) (c) 01/01/06 15. OP24 16 (2) (c) 31/12/05 16. OP24 16 (c) 31/03/06 17. OP24 23 (2) 31/03/06 18. OP25 13 (4) (a) 31/03/06 Page 26 St Katherine`s Version 5.0 low temperature surfaces. This is unmet from 16.11.04, 14.3.05 & 12.9.05. Liquid soap and paper towels must be provided in all bathrooms, toilets, en-suite facilities and the laundry. This is unmet from 16.11.04, 14.3.05 & 12.9.05. The laundry must be clean at all times. Soiled linen must be handled and stored properly. Holes in the wall must be plastered. Staffing levels must be kept under review to make sure that there are sufficient staff on duty at all times. All people working in the home must be identified on the rota. Night care practices must be reviewed to make sure that staff on duty can hear the call system at all times. The manager must notify the 08/12/05 Commission for Social Care Inspection of all significant events affecting residents. Window restrictors must be fitted 31/01/06 on all windows. This is unmet from 16.11.04, 14.3.05 & 12.9.05. Fly nets must be fitted, and used at all times, to the windows and door in the kitchen. The insectocutor must be used in the kitchen. Staff must not enter the kitchen unless they are wearing DS0000001499.V271512.R01.S.doc 19 OP26 13 (3) 01/01/06 20 OP26 13 (3) 01/01/06 21. OP27 18 (1) (a) 01/01/06 22. OP37 37 23. OP38 13 (4) (a) 24 OP38 13 (3) 01/01/06 25 OP38 13 (3) 08/12/05 Page 27 St Katherine`s Version 5.0 26 27 28 29 OP38 OP38 OP38 OP38 13 (3) 13 (3) 13 (3) 13 (4) (a) protective clothing, such as a tabard, apron or white coat. Staff and visitors must not enter or leave the home through the kitchen. Good food hygiene practices must be followed in the kitchen at all times. Pets must not be allowed in the kitchen. Toiletries must not be left in bathrooms. Cleaning materials and aerosols must be stored safely and securely when not in use. Footplates must be fitted to wheelchairs when transferring residents, unless the reason for not doing so is explained in the person’s care plan. 08/12/05 08/12/05 08/12/05 08/12/05 39 OP38 13 (4) (c) 01/01/06 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. Abbreviations should not be used in any records or care plans. This is unmet from 12.9.05. A signed agreement from the residents GP should be DS0000001499.V271512.R01.S.doc Version 5.0 Page 28 2. 3. OP7 OP9 St Katherine`s obtained confirming his/her consent to the use of homely remedies. When a homely remedy is used a record should be made on the resident’s medication administration record. A refrigerator for the sole use of storing medication that requires cold storage should be obtained. Medicine bottles should be cleaned after use. The medication trolley should be cleaned on a regular basis. A record should be made of the date when eye drops are opened. Glass tumblers should replace the plastic beakers currently in use. A formal system of menu planning should be introduced. 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. Where money is handled on behalf of residents, signatures should be obtained from the person handing over the money and the person receiving the money. Receipts and records of all transactions should be kept. 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. 4. 5 OP9 OP9 6 7 8 9 OP9 OP15 OP15 OP33 10 11 OP33 OP35 12 OP38 St Katherine`s DS0000001499.V271512.R01.S.doc Version 5.0 Page 29 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. 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