Inspection on 15/12/05 for St Mark`s Nursing Centre

This inspection was carried out on 15th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Mark`s Nursing Centre 23/10/07

St Mark`s Nursing Centre 25/05/06

St Mark`s Nursing Centre 06/07/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE St Mark`s Nursing Centre 110 St Marks Road Maidenhead Berkshire SL6 6DN Lead Inspector Susan Cledwyn-Davies Unannounced Inspection 15th December 2005 10:00 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 Mark`s Nursing Centre DS0000062781.V270604.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 Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Mark`s Nursing Centre Address 110 St Marks Road Maidenhead Berkshire SL6 6DN 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) 01628 582800 01628 582899 ANS Homes Limited Mrs Nicola Mary Stone Care Home 80 Category(ies) of Old age, not falling within any other category registration, with number (80), Physical disability (0), Physical disability of places over 65 years of age (80) St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: This nursing home is newly built and completed in 2005. The decoration and furnishings are of good quality and provide a very attractive environment. The home is built next door to the local hospital and is accessed via the Hospital grounds. The home is arranged to provide four wings with separate lounge and dining rooms. All rooms are spacious and have ensuite facilities of a toilet, hand basin and shower. The home is arranged over 2 floors. There are gardens with seating arranged round the home. The home is close to the centre of Maidenhead, with a large shopping centre and other community facilities. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.50am and 2.30pm. Included in the inspection was a partial tour of the home, discussion with senior staff and other staff members, conversation with 6 residents and relatives, plus examination of some records. An action plan has been received showing that requirements and recommendations have been followed up. What the service does well: What has improved since the last inspection? What they could do better: The care given to people with risk of pressure sores and treatment following should to improve. The internal monitoring of pressure sores should also be better. Feedback from the home shows that care of pressure sores on the one Unit has greatly improved. A fire risk assessment is important and needs to be in place. Additionally all significant events badly affecting service users have to be reported to CSCI. Service user photographs should be included in care plans and on medication charts and staff photographs should be include in recruitment files. A registered manager is important to coordinate care and ensure good standards. Ensuring that there is a named senior nurse in charge of the home at all times is important. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 6 Staff training records need to be updated and the acting manager aware of training needs. 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 Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 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 Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users were assessed prior to admission. EVIDENCE: Service users on two wings, Ascot and Eton, were assessed prior to admission by the home staff. Preadmission assessments were seen. On Henley wing a senior nurse completed the pre-admission assessments. The local health service has contracted to use this wing for intermediate care. NHS staff based in the unit provides specialist services such as physiotherapy and occupational therapy. There was a previous requirement to ensure that preadmission assessments were completed for all service users. In discussion with senior staff this was confirmed. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Each service user has an individual plan of care; some plans do not include service users photographs. Health care needs are mainly met; the exception is pressure area care on one wing. Medication is safely managed except that some photographs of service users are missing. EVIDENCE: There was a previous requirement that all care plans were reviewed and that qualified staff have training in using the systems. A care plan was seen on each of the three wings. These were better organised and information was easier to access. Recent care plans did not include a current photograph of the service users. New care plans are being put in place following the new proprietors format. On inspection the inspector was advised that there were 6 pressure sores on Henley Wing, none on Ascot and a recovering sore area on Eton. Of the 6 sores four had started on the wing. The senior sister on Henley Wing was unclear of the severity of each sore and did not maintain a central record of progress. There was a record of daily dressings to be completed. There are up to 20 service users on this wing. This level of poor pressure area care is St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 10 very concerning. There is no central management return on a monthly/bimonthly basis to alert the manager to difficulties. In discussion with the senior sister there is a shortage of specialised mattresses. This has been noted in an incident form to the care manager. On the unit when looking at the care plan of a service user with a deep pressure sore there were no specific records of turning and further care to prevent/improve the sore. It is very important that pressure area care on this wing is improved and that there is an overview of practice by the manager of the home. Following inspection an action plan was received. Pressure area care has been reviewed and staff given guidance and training. Turning and standing charts are in place and nutritional guidance given to residents. There is now one pressure sore which is improving and the remainder are vulnerable areas. There is a central record maintained and monthly returns sent to the regional office. The head of nursing reviews all pressure sores. Medication is administered and managed by qualified staff. The medication practice and storage was seen on one wing, Ascot. The storage and administration of current medication was good. Medication no longer needed was now not to be returned to the pharmacy for disposal. Alternative arrangements are being set up but are not yet clear. The record of medication being disposed of had lapsed and must continue to be maintained, to enable an audit trail for all medication in the home. Also all staff need to be aware of how medication is being securely disposed of. Medication administration records of recent service users did not include a current photograph to assist qualified staff when administering medication. This is important when agency staff or unaccustomed staff from another part of the home are administering medication. The medication store for controlled drugs is within a locking cabinet. The legislation asks for a locking cabinet inside a locking cabinet. In this case the door is seen as the second lock. All staff are reminded that the door of the store must be kept locked. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. There are a variety of activities available and service users enjoy these. Service users right to choose is recognised. EVIDENCE: The activities organiser prepares a variety of activities. A weekly newsletter is prepared for service users plus a monthly activity plan is put on each wing. Service users enjoyed the activities arranged on that day; carol singing by a local senior school. The organiser keeps a record of the people who attend trips out and special activities. She tries to include as many people as wish to. Activity equipment had recently arrived and was being prepared for use. The organiser tries to arrange different activities, e.g. Christmas card bingo. Service users spoke having choice of meals and in their daily routine. The inspector saw this during the visit. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users and relatives are confident that their complaints will be listened to. EVIDENCE: There is a responsible approach to complaints. The record of complaints received show that the management of the home is responsive. Recent complaints need to continue being be followed up by the new acting manager. It is difficult to have a responsible and proactive approach when the manager responsible for the home changes as recently. It is important especially as this is a new home that a manager is appointed as soon as possible. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home is well decorated and maintained. The environment is fresh and clean. EVIDENCE: This new home is well decorated and furnished. The home is kept clean and fresh smelling. There is a current application to change the category of residents to accommodate people with dementia on one wing. Work is planned to make some adaptations to one wing in the near future. The plans for this have been sent to CSCI. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 14 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, 29 and 30. Care is provided by an adequate number of staff with varied skills. Recruitment files demonstrate sound practice except no current photographs of staff are included. Staff training takes place regularly. Records kept are not fully updated and there is no central monitoring record. EVIDENCE: Staff cover was seen as adequate, care was given in satisfactory time and staff had sufficient time to give individual care. The exception to this is the findings in standard 9. There were 2 previous requirements, firstly that there is 2 qualified staff in the morning on Henley Wing and that the job description for the senior nurse be prepared. Both of these have been achieved. Recruitment files were organised and checks took place, including references, CRB and interviews. The exception was that there were no current photographs of care staff included in the file. The staff training records were kept on the computer for each individual. These records were not up to date. Plus there is no central monitoring record for the manager to be sure that all staff have had sufficient training and in the right topics. There is some difficulty at the moment as new record systems from the new proprietor are being put into place. A requirement is made to ensure that training records are updated as soon as possible. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. There is no registered manager; arrangements are made for a current manager to visit the home for part of the week. Quality assurance is still developing in the home. Service users finances are safeguarded. Health and safety of service users is promoted except for needing a fire risk assessment and ensuring that notice of significant events is made to CSCI. EVIDENCE: The manager resigned over a month ago. Since then there have been two senior managers appointed subsequently to oversee the home. Interviews have been held and as yet the new manager has not been appointed. There is a current application to change the use of one wing for people with dementia. It is important that a manager is appointed to introduce this change. There is no clear system to advise of the senior nurse on duty, e.g. the person who is aware of the whole home and is seen as the person responsible. A system for noting the senior on duty should be initiated. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 16 Quality assurance is still developing. The annual business plan is a financial document. Questionnaires of service users and relatives have not taken place yet. There has been a recent meeting with service users and relatives. There were a number of questions offered about the home and it was acknowledged by senior staff that the home is still developing. Service users finance is safely stored and clear records are maintained. Receipts are kept and written records given to service users/relatives on demand and with a request for more money. Equipment and house health and safety records were seen during the registration earlier this year. A lot of equipment is still under manufacturers guarantee. Fire testing and records were seen during this visit. Weekly testing of the system and fire drills were maintained. The Fire risk assessment for the house was not present. There was knowledge of a previous risk assessment but a new risk assessment is being prepared. This is made a requirement. The call bell system on Henley wing was out of order for a week recently. This was not advised to CSCI under regulation 37. St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 17 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 X X 3 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP7 OP8 Regulation 15 12 Requirement It is required that all care plans contain a current photograph of each service user. It is required that pressure area care be improved on Henley Wing. Action plan reported good improvement. It is required that the manager monitors pressure area wounds on a regular basis. Action plan reported wounds are reviewed and monitored to head office monthly. It is required that all medication administration records include a current service user photograph. It is required that there is a record of all disposed of medication and that staff are sure of the procedure. It is required that all recruitment files contain a photograph of the member of staff. It is required that training records be up to date and include a central training record. It is required that a registered manager be appointed. DS0000062781.V270604.R01.S.doc Timescale for action 01/01/06 01/01/06 3 OP8 12 01/01/06 4 5 OP9 OP9 13 13 01/01/06 01/01/06 6 7 8 OP29 OP30 OP31 19 18 8 01/01/06 01/02/06 01/02/06 St Mark`s Nursing Centre Version 5.0 Page 19 9 10 11 OP31 OP38 OP38 18 23 37 It is required that a named senior nurse be in charge of the home at all times. It is required that a fire risk assessment be prepared and available. It is required that all significant events affecting service users are reported to CSCI. 01/01/06 01/01/06 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. Refer to Standard Good Practice Recommendations St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Mark`s Nursing Centre DS0000062781.V270604.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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