Inspection on 06/07/05 for St Mark`s Nursing Centre

This inspection was carried out on 6th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 15/12/05

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 MARKS NURSING CENTRE 110 St Marks Road Maidenhead Berks SL6 6DN Lead Inspector Susan Cledwyn-Davies Unannounced 6 July 2005, at 8.55am-2.20pm 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 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 MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Marks Nursing Centre Address 110 St Marks Road, Maidenhead, SL6 6DN Telephone number Fax number Email 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 enquiries@stmarks.ansplc.co.uk ANS Homes Ltd Mrs Nicola Mary Stone Care Home (CRH) 80 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A 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, handbasin 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 MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 8.55am and 2.20pm. Included in the inspection were discussions with the manager, 9 residents and 8 staff. There was a partial tour and examination of records. This was the first inspection since the registration of the home in April. There were 37 residents in the home. There was also discussion with professionals and visitors to the home. It was agreed with the manager that the term residents would be used for service users in the report. What the service does well: What has improved since the last inspection? 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. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 7 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 standard(s) 1, 3 and 6 Prospective residents and relatives are given information about the home. A preadmission assessment of prospective residents generally takes place prior to admission. Service users in the intermediate care wing are assessed and helped to maximise their independence. EVIDENCE: The statement of purpose and service user guide are prepared and given to prospective residents and relatives. All prospective residents are assessed prior to admission to ensure that the home can meet their needs. There was one exception found of 2 residents that were admitted as an emergency admission. The manager stated this would not be repeated. The intermediate care wing is run under contract with the local NHS. There is a lot of support staff with physiotherapy staff and an equipped gym based in the home. This unit is also well supported by the local GP practice with daily visits. There are regular multi-disciplinary meetings to ensure good support and care so that residents can return home within 6 weeks. Occasional residents are exceptions to this and may stay longer for a specific reason. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 8 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 standard(s) 7, 8 and 10 Care plans are in place though not fully completed. Medical care is provided by a local GP practice. Residents felt they were treated with respect and able to stat in their own room or join other people. EVIDENCE: There is a comprehensive care planning system but this is not being completed consisitently. On the intermediate wing there are specific problems because of the speed of change of residents and the use of the documentation. As a result keeping the care plans updated has become very difficult. On the other wing the care plans have not been maintained properly either. Monthly reviews were delayed and following an emergency admission care plans and risk assessments were not fully completed. During discussion with staff there are differences in the way that staff are completing the care plans. There is also a possibility that sometimes too many records are being maintained. The manager will arrange for care plan training to take place and also to arrange for all care plans to be reviewed. There was positive feedback from residents about the care given and approach of staff. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 9 The inspector observed one event that demonstrated lack of respect. One resident was sitting on a chair without clothes from the waist down with a sheet over his legs and front. He was sitting with his wife with his bedroom door open. His wife was concerned about his trousers. This was queried with staff and apparently had been the situation since night staff departed over an hour ago. The care plan for this recently admitted resident was incomplete. The manager was asked to investigate the situation. The report was received prior to this report being sent. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 10 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 standard(s) 13 and 15 Residents maintain contact with family and friends and receive a wholesome balanced diet. EVIDENCE: The activities organiser is scheduled to start shortly. Family and friends were visiting the home. They spoke of staff being friendly and welcoming, refreshments were offered. The kitchen is well organised, run by the catering manager. The assistant chef will start soon. There is a choice of meals offered and all residents are asked for their choice the day before. All residents spoke well of the meals both in quality and amount. The midday meal seen during the inspection was hot and tasty; residents enjoyed it. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18 Residents’ complaints are listened to and acted upon. Residents are protected from abuse. EVIDENCE: There is a complaints procedure. Complaints received have been managed fairly and in a timely fashion. All staff have completed induction training which included some protection of vulnerable adults training. The manager has a copy of the latest multi-agency guidelines for managing vulnerable adults issues. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 12 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 standard(s) 19 and 26 The house is well decorated and furnished. The house is clean and pleasant; laundry facilities are adequate. EVIDENCE: The house is very well decorated and furnished. New furniture and equipment have been purchased. The home was fresh smelling, neat and tidy. The laundry contains a number of washing machines and dryers. At present the household staff all cover the laundry, a designated person will be starting shortly. The household staff work hard to maintain a pleasant environment. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Sufficient staff meets residents’ needs on one floor with some shortage on the intermediate floor. EVIDENCE: On the intermediate wing the staffing on the day was on the rota as 2 RGNs and four carers, one of which was senior. One of the qualified staff was attending a training course in the morning. The inspector was advised by visiting professionals and staff on duty that one qualified member of staff on duty was not sufficient. This was confirmed by observation. It was agreed with the Manager that there would always be 2 qualified staff in the morning during the week. This is made a requirement. The intermediate care is very busy with regular even daily changes in care and frequent discharges. The maximum period of stay aims to be 6 weeks. Exceptions are only made with good reason. Active care is given by NHS physiotherapists and occupational therapists based in the home. There are daily visits by medical staff. Therefore this unit is very busy. There have been recent changes in the management of the intermediate wing. The general manager has responded to the need to provide more management on this floor. One of the registered nurses has been named as unit head in charge of discharges. The job description for this role has still not been agreed and there is some confusion about the role. A requirement is made to clarify this. In discussion with staff the lack of administrative support to this unit brought extra work to the qualified staff. The qualified staff are completing admin work ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 14 when their time would be better spent providing care and maintaining care records. This is therefore made a recommendation. The other wing has sufficient staff but appeared slightly disorganised. The Head of care is leaving and the newly appointed Head of Care is beginning induction. Residents spoke well of the care and the friendly helpful approach of staff. This was also observed during the visit. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 The home is run by a qualified and experienced manager. EVIDENCE: The manager is qualified and experienced having run large nursing homes before. There has been a lot of work in opening the home and developing the staff group. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x x ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 17 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. 2. 3. 4. Standard 3 7 7 27 Regulation 15 15 15 18 Timescale for action That all prospective residents are 1.8.05 assessed prior to admission. That care planning training take 1.8.05 place for qualified staff. That all care plans are reviewed. 1.8.05 That there is always 2 qualified 1.8.05 staff during the week in the morning on the Intermediate wing. That the job description for the 1.9.05 senior nurse on the Intermediate wing be prepared. Requirement 5. 27 18 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 27 Good Practice Recommendations That administrative support be considered for the intermediate wing. ST MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 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 MARKS NURSING CENTRE H52-H01-S62781-St Marks Nursing CentreV236335-060705-Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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