Care Home: St Catherines Rest Home,

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What the care home does well The inspector believes that this is a generally well run home, providing good levels of care and support. Service users and relatives spoken to expressed satisfaction with the home, one service user commented that "I have had no reason to complain since I came here." While a relative said "They look after the residents very well, when one is visiting, you`re always treated kindly." The home has a varied activities programme, including professional entertainers, and food is of a good standard. The home presents as been welcoming and homely, and the physical environment is well maintained. There is evidence that the home has sought to meet the equality and diversity needs of service users, for example through menu planning and the provision of day services. What has improved since the last inspection? There have been considerable improvements to the home since the previous inspection, and the overall number of requirements set has fallen from eighteen to three. The standard of care planning has improved, and the home now keeps clear records of medical appointments. Health and safety management has improved, regular fire drills are now held, and the home routinely tests hotwater temperatures. Only trained staff now administer medications, and the home is free from offensive odours. CARE HOMES FOR OLDER PEOPLE St Catherines Rest Home, 15-17 Cann Hall Road Leytonstone London E11 3HY Lead Inspector Rob Cole Unannounced Inspection 19th June 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherines Rest Home, Address 15-17 Cann Hall Road Leytonstone London E11 3HY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8555 2583 020 8555 2583 stcathscare@yahoo.co.uk Mrs Ann Ratcliffe Mr Keith Ratcliffe Lavinia Cassidy Care Home 19 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 19 14th June 2007 Date of last inspection Brief Description of the Service: St. Catherines is a privately run care home registered to accommodate 19 elderly people. The home is situated in Cann Hall Road in Leytonstone, in the London Borough of Waltham Forest. The home is located in a residential area within easy access to community resources. There are two double bedrooms and 15 single bedrooms. The home provides five single bedrooms and two double bedrooms with en-suite facilities. As well as care staff, the home also employs designated cooking and cleaning staff. The home is privately run. The current range of fees charged by the home is between £485 and £540 per week. St Catherines Rest Home, DS0000007231.V365792.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 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place on the 19/06/08 and was unannounced. The inspector had the opportunity of speaking with service users, a visiting relative and staff from the home. The homes manager was present throughout the course of the inspection, and the homes proprietor was present for much of the inspection. The inspection included observations of staff interactions with service users. The inspection included an examination of records and other documents, along with a tour of the premisis. Prior to the inspection the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. The CSCI also received feedback surveys from service users and relatives, all of this has contributed to the overall inspection process, and has been used to inform judgments made within this report. What the service does well: What has improved since the last inspection? There have been considerable improvements to the home since the previous inspection, and the overall number of requirements set has fallen from eighteen to three. The standard of care planning has improved, and the home now keeps clear records of medical appointments. Health and safety management has improved, regular fire drills are now held, and the home routinely tests hot St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 6 water temperatures. Only trained staff now administer medications, and the home is free from offensive odours. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose, this states that the aim of the home is “To foster an atmosphere of care and active support which both enables and encourages our residents to live as full, interesting and independent lifestyle as possible enabling participation and inclusion.” The Statement included details of services and facilities provided and details of the staff team and their qualifications. The Statement is written in plain English. The inspector was St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 9 pleased to note that since the previous inspection the Statement has also been developed in a pictorial format as well as a written version, thus helping to make it more accessible to service users, and meeting needs around equalities and diversity. The home also has a Service User Guide in place. This was in line with National Minimum Standards (NMS). Both the Guide and the Statement of Purpose have been dated, and are subject to regular review. Contracts/statements of terms and conditions are in place for all service users. These have been signed by the inspector and a representative of the home. They include details of fees payable, what fees cover and what is extra. Through reading service users files, there was evidence that the homes manager carries out a pre admission assessment of their needs, to verify that this home would be a suitable placement, assessments seen covered needs around mobility, personal care and medication. The home has an admission procedure, and this states that prospective service users are able to visit the home before making a decision as to move in or not. Feedback from surveys sent to service users and their relatives confirmed that this is indeed the case. Service users will initially move into the home on a trial basis, after which a placement review meeting will be held. There was evidence on file of these meetings taking place for service users admitted to the home since the previous inspection. The home does not provide intermediate care. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is generally meeting the health and personal care needs of service users. Service users have access to health care professionals as appropriate. The administration of medications within the home has improved, although some attention is still needed in this area. EVIDENCE: Care plans are in place for all service users. These have improved since the previous inspection, and are now of a satisfactory standard. Plans are drawn up with the involvement of the service user, their relatives and the homes manager and are subject to regular review. The inspector checked several care plans at random, and these were found to cover needs around medication, St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 11 personal care, mobility and equalities and diversity issues such as religion and ethnic background. Risk assessments are also in place for all service users, and these likewise are of a satisfactory standard and subject to regular review. Each service user has a separate risk assessment in place around falling and nutrition, and a general risk assessment covering any other potential risks for example around smoking or accessing the community. Assessments identify risks, and include strategies to manage and reduce those risks. All service users are registered with a GP. The manager informed the inspector that service users could retain the GP they had prior to admission where practical. Since the last inspection clear records are now maintained of medical appointments, including details of any follow up action necessary. Records indicated that service users have access to health care professionals as appropriate, including dentists, opticians, CPN’s and physiotherapists. The home carries out health related checks on service users, for example monthly weight checks. The home arranges for general exercise classes to improve mobility and general fitness. The district nurse is involved in drawing up continence plans with service users, and since the previous inspection used continence products are now stored appropriately. There was evidence that the home has built up good relations with health care professionals. As part of the homes quality assurance process, the home seeks feedback from health care professionals through the use of questionnaires. Completed questionnaires seen by the inspector contained positive feedback, a GP commented that “They clearly go above and beyond the call of duty to make their lives enjoyable.” While a district nurse wrote “The home has a very friendly and warm environment.” The home has a comprehensive medication policy in place, and the inspector was pleased to note that since the previous inspection only staff who have undertaken training have responsibility for administering medication. Medications are stored in a locked cabinet, and in a lockable container within the fridge. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained. Although the standard of these has improved since the previous inspection, they were still found to contain some unexplained gaps. For example, one service user has been prescribed FLUCLOXACILLIN tablets. However, the MAR charts for the 18/6/08 were left blank, thus making it impossible to determine if these tablets had been administered or otherwise. In order to ensure that service users receive prescribed medications as appropriate, it is required that clear records are maintained of any medications administered in the home. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 12 Through observation and discussion there was evidence that service users are treated with respect and dignity, and that privacy is respected. Care plans make clear that service users are encouraged to manage their own personal care as much as possible. Staff were observed to knock and wait before entering bedrooms. Service users have access to a telephone they can use in private, and the manager informed the inspector that they could have a phone installed in their bedroom upon request. Service users are given their own mail to open where appropriate. The home has sought and recorded the wishes of service users on the arrangements to be made in the event of their death. The homes manager informed the inspector that service users could remain in the home with a terminal illness, so long as the home could meet their medical needs. St Catherines Rest Home, DS0000007231.V365792.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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live valued and fulfilling lives. Various social and leisure activities are provided, and the food was of a satisfactory standard. EVIDENCE: Several service users attend various day services. In part, these services help to meet service users needs around equalities and diversity issues. For example, one service user attends a service for older people from the Caribbean, while another attends a “New Testament” day service. Service users religious needs are further met by visiting representatives from the Jehovah’s Witness along with the Catholic and Baptist churches. Along with day services, service users are also supported to visit various local community facilities such as shops and cafes, and the home arranges occasional day trips, for example to Southend. Service users are also able to St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 14 go out with family and friends, for instance one service user goes to the local pub with his son once a week. Service users are able to visit local hairdressers, and there are staff that work at the home who are able to provide hair care, including traditional hairstyles from various cultural backgrounds. The local library visits, and service users have access to large print books, again helping to meet needs around equality and diversity issues. In-house, the home provides a variety of social and leisure activities. Service users have access to television and music. The inspector was pleased to note that copies of large print TV guides were available within the home. Staff support service users with sing-a-longs and dancing, flower arranging and on the day of inspection staff were seen to be playing cards with service users. Staff support service users with beauty treatments such as manicures. The home arranges various parties, for example to celebrate Christmas. Various professional entertainers are booked, including Mobility London who provide fitness and exercise classes. Other entertainers perform costume and theatre productions, sing-a-longs and reminisance sessions. A professional singer/comedian was performing in the home on the day of inspection. The inspector sat in for part of this session, and service users were seen to be enjoying this. It was positively noted that staff made efforts to engage service users in this activity. One service user was heard to comment at the end of the performance “Oh, that was smashing that.” Photographs are on display around the home of service users participating in various activities, which helps to promote a homely and welcoming atmosphere. Visitors are welcome to the home at any reasonable time, service users informed the inspector that they can see visitors in private if they so wish. The inspector spoke with a relative on the day of inspection, who said that they are always made very welcome and commented that “I have no complaints, I could not ask for anything more.” Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection service users were offered a choice of sausages or meat pie, both served with potatoes and fresh vegetables. The days choice of menu was clearly on display in the dining area. Service users spoken to said they liked the food, one commented “I enjoy the food here, its very nice.” The home seeks to meet service users needs around equalities and diversity through the provision of food, for example through traditional British and Caribbean food. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home has taken appropriate steps to ensure that service users are safeguarded from the risk of abuse, although the home must ensure that its adult protection procedure is in line with current legislation. EVIDENCE: The home has a complaints log, two complaints have been received since the previous inspection, and the log indicated that both of these have been recorded and investigated as appropriate. The home also has a complaints procedure, which is included within the Service User Guide. A copy of the procedure was on display within the home. This made reference to the CSCI, and included timescales for responding to any complaints received. The AQAA supplied by the home indicates that it is planned to discuss the complaints procedure and how to make a complaint regularly with service users and relatives through meetings. The home is situated in the London Borough of Waltham Forest, and has a copy of the Borough’s adult protection procedure. The home also has its own adult protection procedure. However, as at the last inspection, this is not in St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 16 line with current legislation. For example, it does not make clear the homes responsibility to report any allegations of abuse to the Local Authority. It is a requirement that the home has an appropriate and up to date adult protection procedure in place, which is in line with current legislation. The inspector was however pleased to note that since the previous inspection all staff have now undertaken training in safeguarding issues, and that staff spoken to during the course of the inspection demonstrated a good understanding of their roles and responsibilities with regard to adult protection. There was evidence that the home seeks to protect the legal rights of service users. All service users are on the electoral register, and those who chose to were able to vote in the recent local government elections. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to the physical environment. The home was generally well maintained, and service users have access to adequate communal and private space. EVIDENCE: The home is situated in the Leytonstone area of the London Borough of Waltham Forest. It is in a quiet residential area, close to shops, transport networks and other local amenities. The home consists of two houses that have been converted into one, and is built over two floors, with a service lift connecting the floors. It is in keeping with other homes in the area. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 18 The home was generally well maintained, both externally and internally. Communal furniture was well maintained and domestic in character. Communal areas consist of a lounge, another lounge/dining area, the kitchen and the homes garden. This was well maintained, and included appropriate garden furniture. Service users were seen to be enjoying spending time in the garden on the day of inspection. It was observed that service users have unrestricted access to communal areas of the home. Since the previous inspection the communal hallways have been decorated, service users were involved in choosing this new décor. The home has adequate numbers of toilets and bathing facilities, with a choice of bath or shower. Bathrooms were clean, tidy and free from offensive odour, and all had impermeable floor coverings. The inspector was pleased to note that since the previous inspection all bathrooms and toilets are now fitted with a working lock, which includes an emergency override device. The home is registered for nineteen service users, and comprises fifteen single bedrooms and two double bedrooms. Seven of the bedrooms have ensuite facilities, while all the others all include a hand basin. Bedrooms meet National Minimum Standards on room size requirements. Service users have been able personalise bedrooms to their own tastes, for example with televisions and family photographs. They contained adequate furniture, including table, chair, chest of draws and wardrobes. Bedding, carpets and curtains were well maintained and domestic in character. Bedrooms have adequate natural light and ventilation, and all had central heating. Radiators have appropriate protective coverings. Emergency alarm call points were installed in all bedrooms and bathrooms. The inspector tested one of these, and found there was a prompt response from staff. Bedrooms were clean and tidy. At the last inspection it was found that two bedrooms had an offensive odour, and that screening was not provided in double bedrooms. The inspector was pleased to note that both of these issues have now been successfully addressed. The home has various adaptations in place to help make it accessible to service users, and to meet their needs around equality and diversity issues. As mentioned, there is a service lift between the two floors, and the home uses hydraulic hoists. Toilets have handrails fitted, and baths and showers have both been adapted to make them accessible to service users. The garden is connected to the home via a ramp. The home has taken steps to help prevent the spread of infection. Staff have undertaken training in infection control, and protective clothing such as gloves and aprons are available to staff. The home has laundry facilities suitable in scale for the home. Hand washing facilities are situated around the home, and COSHH products were stored securely. St Catherines Rest Home, DS0000007231.V365792.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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection, and since the previous inspection now indicates who is in charge of the home at any given time. Through observation and discussion there was evidence that staff have built up good relations with service users, and had a good understanding of the collective and individual needs of service users. Throughout the day staff were seen to interact with service users in a friendly and respectful manner. There were instances of positive staff interactions with service users, for example playing cards and encouraging service users to dance and sing-a-long with the visiting entertainer, which service users appeared to enjoy. The inspector had St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 20 the opportunity of speaking with a visiting relative during the course of the inspection, who spoke highly of the staff, commenting that “As far as I am concerned, the manager and staff here are brilliant.” Staff have been provided with a written contract and job description. All staff undertake a structured induction programme on commencing work at the home, records are kept of this to verify when each part of the induction has been completed, for example around health and safety or care planning. Staff have access to training, and recent training has included adult protection, first aid, food hygiene, moving and handling and the Mental Capacity Act. The inspector was pleased to note that all but one of the care staff working in the home have successfully achieved a relevant care qualification. According to the AQAA, the home has all relevant employment polices in place, the inspector checked the policy on equal opportunities, and this was found to be satisfactory. The inspector checked several staff employment files. Since the last inspection these now all contain appropriate CRB checks. However, they still do not all contain all documentation required by the Care Homes Regulations, for example for two staff there was no proof of ID, for one staff their was only one employment reference in place, while another did not have any references at all. To help ensure that the home appoints appropriate staff to help reduce the risk of service users been abused, it is required that all necessary employment checks are carried out for all staff working in the care home. St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors view that this is a generally well run home, and that the manager is sufficiently qualified and experienced to carry out their duties. EVIDENCE: The homes manager was first registered with the CSCI in April 2007. They have twenty years experience of working with older persons, including four years in a managerial capacity. They have achieved the Registered Managers Award and a NVQ Level 4 in Care. Staff were observed to interact with the St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 22 manager in a relaxed manner, and staff and service users informed the inspector that they found the manager to be approachable and accessible. The AQAA supplied by the home indicates that the home has all relevant policies and procedures in place in line with National Minimum Standards. Those checked by the inspector, including complaints, admissions and medications were found to be satisfactory, (with the exception of the adult protection procedure as mentioned previously in this report). Record keeping in the home was of a generally good standard, confidential records are stored securely, the manager informed the inspector that staff and service users could access their records as appropriate. The inspector was pleased to note that since the last inspection staff now receive regular formal supervision. Staff supervisions and care plan reviews contribute to the quality assurance within the home. Copies of previous inspection reports are available to view in the home. The inspector was pleased to note that since the previous inspection of the home, the proprietor now carries out monthly Regulation 26 visits, and produces a report from these visits. The home has a system in place for seeking feedback from service users, relatives and social and health care professionals on the care and support provided, through the use of questionnaires. Completed questionnaires seen by the inspector contained generally positive feedback, and this was in line with the surveys completed by service users and relatives for the CSCI. Fire extinguishers are situated around the home, these were last serviced in March 2008. Fire alarms are checked weekly, and have been serviced within the past twelve months. The London Fire Authority visited the home on the 26/2/08 and found everything to be satisfactory. Since the previous inspection the home now holds three monthly fire drills. Fire exits were free from obstruction, and the home has produced a comprehensive fire risk assessment. Emergency alarm call points are located in bedrooms and bathrooms, those tested by the inspector were found to be in working order. The home has in date safety certificates for PAT testing, gas safety and electrical installation. The homes lift is regularly serviced. The home tests fridge/freezer and hot water temperatures, and COSHH products were stored securely. The home has in date employer’s liability insurance cover in place. St Catherines Rest Home, DS0000007231.V365792.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 Requirement The registered person must ensure that all medications are appropriately administered and recorded. (Timescale 30/06/07 not met) The registered person must ensure that all appropriate employment checks are carried out on all staff working at the home, including employment references and proof of identification. (Timescale 30/09/07 not met) The registered person must ensure that the home has an adult protection procedure makes clear the homes responsibility to report any allegations of abuse to the Local Authority. Timescale for action 30/06/08 2. OP29 19 31/08/08 3. OP18 13 31/07/08 St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catherines Rest Home, DS0000007231.V365792.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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