Inspection on 16/09/09 for St Marks Care Home Limited

This inspection was carried out on 16th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 27 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Marks Care Home Limited 17/09/08

St Marks Care Home Limited 04/09/07

St Marks Care Home Limited 11/09/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Marks Care Home Limited 38-40 Wellesley Road Clacton on Sea Essex CO15 3PW     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Louise Bushell     Date: 1 6 0 9 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 40 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: St Marks Care Home Limited 38-40 Wellesley Road Clacton on Sea Essex CO15 3PW 01255421750 01255435282 sandy@sahadew.fsnet.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: St Marks Care Home Ltd care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 17 persons) Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 17 persons) The total number of service users accommodated in the home must not exceed 17 persons Date of last inspection Brief description of the care home St Marks Care Home can provide personal care and dementia care for up to 17 people over the age of 65 years. The home has been converted from two private residences. It is on a residential street in Clacton-on-Sea close to the town centre and sea front. Care Homes for Older People Page 4 of 40 Over 65 17 17 0 0 1 7 0 9 2 0 0 8 Brief description of the care home Accommodation is provided on two floors, with the upper floor being accessed by a passenger lift. Thirteen rooms are single occupancy and two rooms are shared. Residents have a dining area and two sitting rooms available to them. There is a small garden to the rear of the property and limited off road parking in front of the home. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of the inspections undertaken by the Care Quality is upon outcomes for the people who use the service and their views of the service provided. The primary method of inspection used was case tracking which involved selecting a number of people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. The last key inspection took place on the 17th September 2009. The visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Care Quality Commission. We looked at the last Inspection Report and information on safeguarding and Care Homes for Older People Page 6 of 40 complaints since the last inspection. We also looked at the Annual Quality Assurance Assessment (AQAA) and reviewed what the service has improved in the last twelve months and its plans for the next twelve months. During the visit information was gathered directly from the staff, people who use the service and relatives and or visitors to the service. The visit took place between 9:30am and 16:30pm. This enabled the inspector to directly and indirectly observe the care practices and the day to day operations of the service. A selected tour of the building was conducted during which the inspector spoke with people who use the service, staff and visitors and the manager. What the care home does well: What has improved since the last inspection? What they could do better: A number of requirements and recommendations have been during this inspection and include the need for the service to ensure that that assessment truly reflect the holistic needs of the individual and that the service is able to demonstrate its ability to meet that need. The assessment should further explore the equality and diversity issues for each person, ensuring that their preferences are noted and acted upon as required. A copy of the social services pre admission assessment would benefit from being held on file and in addition to this it would be good practice for documents to be signed and dated for internal audit purposes. The service must review its internal management procedure for the management of the level of staff and ensure that all staff are suitably recruited following the service own policy and procedure. The care plan must be developed with the consultation of the person using the service and must ensure that it covers the entire range of the service users needs and any associated risks. Where a risk has been identified additional information, guidance and support must be obtained from the relevant health care professionals. The provision of activities within the services requires reviewing to ensure that what the service is offering is really want the individual wants. The activity provision and variety to increase and widen enabling and empowering people to become more involved and in control. Care Homes for Older People Page 8 of 40 People using the service muster be offered choices of a wholesome and nutritionally balanced meals on all occasions. Complaints must be recorded and action taken as required. The Safeguarding of Vulnerable Adults Multi Agency procedure must be available on site for all staff and people using the service to access at any time. The services own policy and procedure must be reviewed and in line with this guidance at all times. All fire doors within the service must close as required and be fitted with devices as recommended by the local fire authority. The glass in the patio doors must be replaced to enable people to see clearly into the garden. The garden must be maintained and the service even enabling people to access the outside whilst minimising the risk of tripping and falling. The lounge carpet is to be replaced and the flooring in the dinning room to be cleaned and or replaced. The table clothes to be replaced in the dinning area and the the flooring to be reviewed in a bedroom if the mal odour can not be removed. There is a need for the service to ensure that it is kept sufficiently clean especially within the kitchen areas and that a suitable pedal bin is provided to increase positive food hygiene practices. Staff changing and storage facilities must be provided. The service still does not have a registered manager in post. This was discussed with the person in charge of the service at the time of the inspection. It was bought to the persons attention that further enforcement action may be taken if the service fails to appoint a registered manager. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 40 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can not be assured that their full needs are being assessed and that the staff will have the right information in order to provide the care and support that they need or prefer. Evidence: The admission of new people to the service aims to involve the individual as much as possible. The AQAA tells us that expand more and obtain as much information as possible prior to admission. The AQAA tells us little else about how the service has improved and the evidence to show how they do it well. Part of the inspection process involved case tracking two people. Case tracking is a method used to review a persons care package and reviews the person from the assessment stage to the current stage in their lives, including assessments, care planning, risk management and health issues. Where possible the people case tracked are also visited to gain their views directly. Indirect and direct observations also Care Homes for Older People Page 11 of 40 Evidence: occurred in order to establish if the care being provided was as per the care plan. Two people were case tracked as part of this inspection process. The assessment process sets out each separate area of need and how the service is able to meet the needs of the individual. The service also has internal documents in place to ensure that each of the records are completed to a standardised approach, ensuring that the full needs of the person are accurately recorded. Of the two people case tracked it was found that on both occasions the assessments were not fully completed. Examples of this included that the personal history summary was blank, the hobbies and interests were blank as well as the persons cultural and religious needs being left blank. The remainder of the assessment format allows the assessor to tick which area of need applies most to the person using the the service. For example the section on washing, needs assistance is ticked. The assessments reviewed had also not been signed or a date when they were completed. In addition to this a further document has been recently introduced to the service. This is called personal care requirements as perceived by the resident, this shows an attempt to engage with the person and gather information through consultation regarding preferences and choice. However it was observed that this document was blank. The form requests a signature from the person using the service and or their representative, however this was not signed or reasons given why it was not signed. Following discussions with the person in charge during the inspection it was established that the service is in the process of revising documentation and streamlining what documentation is in place and being used. The pre admission assessment does explore some areas off difference and diversity and identifies the persons preferred name, religion, age and wishes in the event of death or a terminal illness. Where this information was requested as part of the initial assessment it was found that the form was blank. The form also explores marital status but does not prompt or identify civil ceremony and partnerships. The service consults the assessment information to see if they can meet the prospective individual needs before they make the decision to accept the application for admission and offer a place. For both of the assessments reviewed as part of case tracking it was directly observed that the service was not in receipt of the assessment carried out by social services. Individuals are provided with a statement of terms and conditions or a contract before admission to the service. It gives basic information on what people who live in the home can expect to receive for the fee they pay, and sets out terms and conditions of occupancy. The contract is normally reviewed when the persons circumstances Care Homes for Older People Page 12 of 40 Evidence: change. The service has developed a statement of purpose, which sets out the aims and objectives of the home, and includes a service users guide, which provides basic information about the service and the specialist care the home offers. The guide is made available to individuals in a standard format. These documents, although available upon request and were on display within the service. Discussions with a persons relative identified that their family had been provided with information about the service prior to moving in and also had an opportunity to visit and ask questions about the service. One person using the service stated my brother helped me move here. The service does not provide intermediate care. Care Homes for Older People Page 13 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can not be assured that their care plans and risk assessments fully assess and record their needs and therefore could place them at risk. Evidence: The care plans of two people living at the service were read to determine how the service supports the needs identified in the persons initial assessments. The care planning format followed the information obtained during the assessment process. Each area of need was identified in a separate care planning tool and covered items such as, eating and drinking, personal hygiene, elimination, dressing, communication, mobility, sociability, oral / mouth care and foot care. Each of the care plans detail the identified need for the individual person followed by the individuals need and outcomes for delivery of the care and support. Each of the care plans seen, followed a similar format, though following discussions with the person in charge it became apparent that a number of documents that were evident in one person care plan was not present in the other. An example of this was seen with the how can things in the service users life be improved and also the residents personal activity assessment. Whilst the care plan then went onto explore the specific needs of the person it did not Care Homes for Older People Page 14 of 40 Evidence: refer to any associated risk assessments with regards to the management manual handling or general environmental risks. One person using the service commented Its lovely here, I have fun with the friends I have made. The staff are always really kind to us. The person in charge spoke to us regarding trying to ensure that all paper work that is required to be held is completed fully and available at all times. The new person centred care planning format does not allow the person completing its review, to review each element of the document. It rather suggests that the document as a whole will be reviewed. Care plans seen had been reviewed. A relative at the service during the day of the inspection commented X is very happy here, so we are happy. X has been here some time and is very settled. We visit on a regular basis and take X out to lunch. In addition this a person using the service commented I like it here, the staff are considerate and I like having my visitors. The care practices observed throughout the day were respectful and dignifying at all times. One care worker was directly observed supporting some one with their lunch. This was achieved in a calm, unhurried manner. In addition to this care staff were observed pulling blinds or curtains if the sun was directly in peoples eyes and asking their permission to do so. Overall the plans do give instruction to staff in meeting the majority of peoples needs, and from observation and discussions with people living at the home and the staff group there was evidence of knowledge of the individuals and their needs. However if the information in care plans was more detailed and responded to all the information staff demonstrated that they knew about the person, it would provide an increased level of consistency in the delivery of the staff support and improve the outcomes of people living at the service. The AQAA contains minimal information from the service regarding how the service evidences it meets the national minimum standards. It states, (in relation to evidence to show that we do it well), that a record is kept in the residents folder. The files seen contained assessments relating to nutritional screening, skin and a moving and handling plan, outlining the needs of person living at the service. These gave an indication of the persons strengths and weaknesses that affect the outcome of their movements. There were no risk assessments in place for the second person case tracked and no additional risk assessments in place of other areas of identified needs and risk. One of the individuals case tracked had a client taking risk record, this record stated that the person had reduced mobility at risk of falls. No additional assessments and or manual handling assessments were held on file for the person. Risk assessments Care Homes for Older People Page 15 of 40 Evidence: identify and support the service in determining a proportionate response to risks presented in peoples daily living whilst recognising their rights to live their life in as independent a way as possible. Without the process of risk assessment the service is unable to ensure these rights and protection of an individual are supported. The person in charge on the day of the inspection stated that they are not in contact with the falls adviser for the local area. The service maintains some records that monitor peoples health and wellbeing such as regular checks on their weight and fluid intake. This provides tools that give indications of changes in the persons wellbeing which may require action by the service. The service uses a number of recognised tools to identifying deterioration in a person specific health area, which in turn alerts the service to other possible health issues associated with the deterioration. Visits made by medical professionals such as GPs or District Nurses were maintained on peoples files, and included the reason and outcome of the visit. The management of medication administration was reviewed as part of this inspection visit. This included the indirect observation of staff administering the lunchtime round, checks on documentation and discussions with staff. The service has a sound system in place for the safe and accurate administration of medicines for the people who use the service. It was identified that where medication is carried forward from one month to the next that the balance should be carried forward. Care Homes for Older People Page 16 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The variety of activity and social stimulation available at the service could be further improved ensuring that the needs, wishes and preferences of the people using the service are acted upon and implemented. Evidence: Generally staff are aware of the need to support people to develop their skills, including social, emotional, communication, and independent living skills. Some people are consulted or listened to regarding the choice of daily activity, but this process could be improved. The service currently provides a total of ten voluntary hours of activity provision per week. This is on the rota. People using the service are given the opportunity to take part in a selection of activities within the service. Due to the number of people residing at the service, the frequency of community base trips is minimal. There is no formalised activity planner in place. The service has a large white board on display, however at the time of the inspection this had the details of the previous days meals and activities being offered. During the inspection people were observed listening to music, reading news papers and moving freely around the building. Care Homes for Older People Page 17 of 40 Evidence: A person using the service commented I dont know who the activity person is, but the staff are very kind. The AQAA tells us that the service provides social activities as per residents preferences and abilities. The AQAA has also identified that they are planning to improve on the provision of activities and increase the amount of activities provided within the next twelve months. The service has a basic understanding of human rights and how this impacts on people using the service. There is little documentary evidence to support this approach, but staff were directly observed to be respecting and dignifying personal choices and opinions. The service does not document on the person care file restrictions that are imposed upon the person. The initial assessments held on the persons care plan detailed some references to a persons life style and interest, although this is sometimes not completed. The plan also details a section where information is obtained regarding the persons family, working life and what the individual enjoys. It was not apparent that the activity schedule had been completed with the specific interest of the people using the service at all times. There were care plans relating to the social needs of people there were not specific details of how the assessed needs and abilities of people shaped their choices and how staff should support these. Visitors spoken with during the visit said they were made to feel very comfortable during their visit and were welcomed at any reasonable time. People who live at the home said that they felt they were given opportunities to exercise choices during their day. One person spoke about how they enjoyed spending time in their room and actively chose not to take part in activities provided. One person using the service commented we do movement to music on a Wednesday and sometimes play bingo, we also sing. We never go out. Another person spoke about the choice of meals and felt confident that if they chose something else from the offered menu this would be not be a problem, they said the foods lovely. On the day of the inspection the cook and cleaner had rung in sick. There were three staff on duty completing the tasks for five people. One of the care workers was cooking the lunch time meal which was mash potato, beans and fish fingers. No additional choices of meals were observed to be offered. Prunes and custard was offered for pudding, however the stones had not been removed from the prunes. The observation of the lunchtime meal indicated that there was generally a congenial Care Homes for Older People Page 18 of 40 Evidence: atmosphere where people were given time to eat in a relaxed manner. The staff moved around the dining room and lounge serving the meals, encouraging people to eat and offering assistance if required. During the inspection a review of the internal procedures for the management of financial affairs was reviewed. Two people using the service are supported currently with the management of their finances. One persons finances are managed by the service. The person in charge during the inspection provided additional information. It was established that the service is an appointee on behalf of the individual. Care Homes for Older People Page 19 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can not be confident that their complaints will be listened to and acted upon and that they are protected from harm. Evidence: The service has a complaints procedure that meets the NMS and regulations. The procedure is up to date and information regarding the process to complain is located in the entrance foyer of the building. The procedure is not available in alternative formats. Some individuals spoken to as part of the inspection process stated that they know how to make a complaint but others do not. One person using the service stated I dont know how to make a complaint but I would always talk to some on in charge. In addition to this another person stated I think I know how to complain, I am outspoken and speak the truth. Complaints from individuals are not always fully recorded. During the inspection, discussions occurred with the person in charge regarding a recent complaint received, whilst the person in charge had full knowledge of the issues raised there were not formal records maintained, no correspondence or any actions taken. The complaint file had a copy of the procedure held within, however there were no formal and or informal complaints logged at all. The AQAA tells us that the service has identified that they could improve by to resolve all complaints within the given timescales. Care Homes for Older People Page 20 of 40 Evidence: There are policies and procedures for safeguarding people who use the service but these are specific to the service and appeared to not have been reviewed for some time. The policy and procedure did not also incorporate the multi agency approach to safeguarding of vulnerable people. Whilst staff were able to discuss that they would always pass information onto the senior if they saw any kind of abuse occurring they could not further expand their knowledge to discuss that the service has a policy and procedure and that there is a multi agency approach policy in place. The service did not have a copy of the multi agency guidance available. Links with external agencies are adequate but there is a lack of understanding of safeguarding procedures and how they work. Some staff have had training around safeguarding adults but others have a limited understanding in this important area. This leads to inconsistent knowledge and practice within the service. People using the service say that they are satisfied with the care in the service and feel safe. Care Homes for Older People Page 21 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people using the service can not be assured that they are being supported in a safe and satisfactory maintained environment. Evidence: The service is a homely place to live and the bedrooms and communal rooms meet the NMS or are larger. All bedrooms that were seen, were personalised to the individuals own taste. All the services fixtures and fittings meet the needs of individuals and can be changed if their needs change. One person using the service commented I am very pleased with my room. In addition to this one person commented I enjoy my room. Most bedroom doors have the name of the person on a plaque, however the service does support a number of people with Dementia. No additional memory aids were being used at the service. The lay out of the service attempts to encourage people to socialise and engage in small clusters rather than all in one area. The service has many different seating areas available with books and music available to all. The design of the building allows people to move freely throughout with a lift available to move between floors. The environment promotes the privacy, dignity and autonomy of people. This was directly observed during the inspection, where people where seen to be supported to their rooms for personal care and support tasks. Staff were also seen to knock an wait on bedroom and bathroom doors. Care Homes for Older People Page 22 of 40 Evidence: The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of satisfactory quality. Within the last twelve months a ground floor shower room has been installed. The management has a good infection control policy. They seek advice from external specialists, such as NHS infection control staff, and encourage their own staff to work to the services policy to reduce the risk of infection. Hand sanitiser, aprons and gloves were seen to be used and readily available for all staff. A relative commented Its always clean and tidy here. The AQAA tells us that improvements are planned over the next twelve months and include the replacement of a number of bedroom doors. The AQAA tells us that improvements have been made over the last twelve months through the redecoration of all communal areas, new furniture seating and dining furniture. New fence in the garden, tidied the garden, upgrade kitchen. At the time of the inspection it was noted that the kitchen area was dirty and not reflective of a well managed cleaning process and system. Tea and food stains were visible around the walls and the bin area. The bin was not a pedal bin and staff were seen touching the bin to place items in there and then continuing with food handling. There are sections of the kitchen that remain not decorated and bare plaster showing. During a limited tour of the building it was directly observed that a number of bedroom doors did not close properly and that they were being propped open with personal items such as furniture, magazines and weights. These were brought to the attention of the person in charge and they were removed. It was also noted that a strong mal odour was present in one of the bedrooms. This was brought to the attention of the person in charge. In addition to this it was observed that the dinning room table coverings were old, dirty and uninviting. The glass in the patio doors was also blown, limiting the view into the garden area. The garden area was small and reasonably maintained. However the surface was uneven and did not allow people to move freely out side of the building. A number of Care Homes for Older People Page 23 of 40 Evidence: small drain coverings were seen and the surface surrounding these were a trip hazard. There was limited railings around the garden to support with walking. Following discussions with a number of the staff team, it was established that there is currently no provision for staffing facilities. This was brought to the attention of the person in charge. One member of staff stated that we have to leave out bags in the rooms of the service users for safety. This was addressed with the manager. Care Homes for Older People Page 24 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can not be assured that they will receive the care and support and protection that they require due to an inadequate system for covering shortages and recruitment practices not in line with policy and procedure. Evidence: People are generally satisfied that the care they receive to meet their needs. One person using the service stated I like the staff. The person in charge confirmed that there are three care staff working throughout the day with one waking night person and one sleep in person. In addition to this the person in charge is supernumerary. In addition, there are catering, housekeeping and activities staff on duty in the waking day. On the day of the inspection the cook and cleaner had rung in sick and the care staff had to complete the duties of the cook and the cleaner. Following discussion with a number of the staff it was established that if the cleaner calls in sick that they complete light cleaning duties. The service does not use agency staff or have a relief bank list. One member of staff stated that we call around everyone to see if they are able to cover the shifts, if we cant get it covered then we call the manager. The manager stated that the numbers of staff required are arrived at by a calculation of individuals needs, discussions with staff about how they work with people living at Care Homes for Older People Page 25 of 40 Evidence: the service and an allowance of time for the tasks to be undertaken. One staff member commented there are not always enough staff on duty. We dont use agency or relief. we cant. If the cook is off sick we have to cook, if the cleaner is off sick we have to give a basic clean. The recruitment records of the four staff contained documents that supported the employment of people who were suitable to work with vulnerable adults. This included full application forms, references, proof of their identify and CRB checks. In each case the staff had commenced their employment with a POVA first request while the full CRB report was waited for. One staff file was noted to not have a CRB in the name of the work place. This was brought to the attention of the manager. Discussions with staff verified that they undertook a robust recruitment process and were asked to provide supporting documents before they were offered a post. The training programme included items such as health and safety, food hygiene, fire safety and manual handling as having being completed so far this year. Staff spoken with said they had enjoyed the training they participated in and felt that there was training on offer. One staff member stated I am just about to start my NVQ II. The staff have not received any training in the Mental Capacity Act and Deprivation of Liberty and Safeguards. The AQAA tells us that the home has sixty percent of staff with NVQ level 2 training. All new staff receive common induction training within six weeks of employment. Evidence of the inductions were seen on a number of staff files. The person in charge is aware that there are some gaps in the training programme and plans to deal with this. All staff are clear regarding their role and what is expected of them. People using the service report that staff working with them know what they are meant to do, and that they meet their individual needs in a way that they are satisfied with. During the inspection care staff were directly observed supporting people in a caring respectful manner. Care Homes for Older People Page 26 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service cannot be assured that they will be listened to and that there is leadership that plans how to improve the way in which it delivers a service. Evidence: Mrs Sahadew a director of the company, St Marks Care Ltd who owns the service, has been operating as the person in charge. She is a registered nurse and has worked in the residential care sector for nine years. There has not been an application made for registration of a manager with the Commission. Mr Sahadew was present at the time of the inspection and spoke about the reasons why the service has not yet made an application to register a manager. This was discussed at length and established that an application must now be made. Failure to do so may result in enforcement action being taken. Mr Sahadew demonstrated a willingness to learn and improve the quality of the service at St Marks. Progress and complaince has been made with most of the requirements made at the last inspection, however due to an inconsistent, Care Homes for Older People Page 27 of 40 Evidence: unregistered manager in post there are areas of the service that are slipping. This is reflective in the over all quality rating of the service and the number of requirements that have been made. Although the service returned the AQAA when asked to do so there was very limited information about how the home was listening to the people who lived there and was moving towards a greater compliance with the Care Homes Regulations 2001. The primary purpose of the AQAA is to inform the Commission about how the Registered Person understood the strengths and weaknesses of the service in meeting its regulatory obligations and how they were seeking to address these. The quality of the information in St Marks AQAA evidenced a lack of clearly defined planned progress towards a quality service provision. It is important that the organisation and manager identify ways in which they can access information and support in respect of good practice in their care sector and consider how they will incorporate this learning into the service development plans. The manager is liked and respected by the staff and people living at the home. They said that they were approachable and always responded to what they told her. One staff member stated the management will support us if we need it. The manager stated that the service had conducted a quality assurance survey since the last inspection. These documents did not set out how many responses had been received in each category but gave an overall summation of their content. The outcomes centred on central issues such as quality of care, meals and administration. The manager had not produced a published report at the time of the discussion. The stakeholders surveys are an important element of the services quality assurance system. It is important that people who use the service, their supporters and others are asked how their experience of the service meets their expectations. The information gathered from this should be used to inform the services annual development plans and their completion of the AQAA returned to the Commission. The quality of the current format and information gathered by the St Marks surveys and their responses should be considered by the organisation to understand how this affects their overall quality assurance programme and their progress in meeting the National Minimum Standards for Older People 2001. Staff records demonstrated some staff supervision was taking place but that this was not consistently carried out for some staff. The opportunity to give feedback to staff in relation to their performance is an important element of staff development and quality Care Homes for Older People Page 28 of 40 Evidence: assurance. The records relating to the maintenance of health and safety systems and equipment within the service were reviewed at this visit. The certificates for the maintenance of gas and electricity systems, the passenger lift and hoists and fire safety equipment were all within date. The service has a current liability insurance. These records demonstrated a robust approach to the health and safety of people living at the service. Care Homes for Older People Page 29 of 40 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 17 Assessments must reflect an 30/11/2009 accurate record of the needs of an individual. In order to ensure that the service provides care and support as required and recorded. 2 3 14 Assessments must be fully completed and provide detailed information holistically to meet all needs of the person. To ensure that the service is able to meet all needs. 30/11/2009 3 4 17 The service must 30/11/2009 demonstrate its capacity to meet the assessed needs of the people using the service. To ensure that the service is able to deliver the care and support as required and recorded upon assessment Care Homes for Older People Page 31 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 7 17 The service must ensure 16/12/2009 that each person has detailed records maninatined of their care needs and requirments, risks and support. To ensure that people using he service are kept safe and are protected from harm. 5 7 13 The service must implement risk assessments where a risk has been identified. In order to ensure that people who use the service are kept safe from harm. 30/11/2009 6 7 15 The service nmust ensure that a detailed plan of care is in place for each person covering all of their identified needs. To ensure that the fully range of needs for the person are identified, addressed and repsonded to. 16/12/2009 7 8 11 The service must ensure 27/11/2009 that it promotes and maintains an individuals health and ensures access to health care services and external professional support to meet assessed and changing needs. Care Homes for Older People Page 32 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action In order to ensure that the people using the service access services and advice that they require. 8 12 16 The service must ensure 25/11/2009 that a provision for activities is made to ensure people are offered the opportunity to engage in meaningful activity and stimulation. To ensure that the people using the service are offered a varied, flexible and meaning full experience and opportunity to engage in activities and stimulation. 9 13 16 People using the service must be supported, enabled and empowered to access the local comunity as they wish. To ensure that the people using the service are offered a varied, flexible and meaning ful experince and opportunity to engage in activities and stimulation. 10 14 13 The service must ensure 04/12/2009 that suitable systems for the management and safe keeping of finances. These systems must empower people to manage their own 25/11/2009 Care Homes for Older People Page 33 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action financial affairs if they have the capacity to do so. To ensure that the people using the service are produced from possible abuse. 11 14 13 Where the service is 04/12/2009 managing peoples financial affairs additional information and assessments must occur in line with the Mental Capacity Act guidance and Deprivation of Liberty and Safeguards. To ensure that the rights of the person are protected. 12 14 16 People using the service 18/11/2009 must be provided with wholesome, nutritional foods which they have chosen. To ensure that the people using the service are able to exercise choices and preferences within their lives. 13 16 13 The service must ensure 12/11/2009 that complaints are recorded and managed in line with the services own policy and procedures. To ensure that people are empowered and enabled to make complaints. Care Homes for Older People Page 34 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 14 18 13 The service must ensure that the policy and procedure regarding the safeguarding of vulnerable people is reviewed and in line with the multi agency approach. To ensure that people are supported and protected from harm. 12/11/2009 15 19 23 The service must ensure that the service is kept clean. In order to ensure that the people using the service are kept safe. 12/11/2009 16 19 13 A suitable bin must be provided. To ensure that staff are able to conduct sound food hygeinbe practices. 06/11/2009 17 19 23 The kitchen area must be redecorated and provide suitable areas for the preperation of foods To ensure that the environment where food is being prepared is clean and safe. 30/11/2009 18 19 23 The service must replace the 30/11/2009 lounge carpet and make good the dinning room flooring. Care Homes for Older People Page 35 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that people live in an attractive, safe environment. 19 19 23 The service must provide suitable changing and storage facilities for staff. To ensure that the staff are able to store valuable items in the work place safely. 20 19 22 The service must ensure that the glass to the patio doors is replaced. To ensure that people using the service are residing in a conformable safe environment. 21 19 13 The service must ensure 30/11/2009 that doors are suitably fitted and have devices as recommended by the fire authority to hold them open as required. To ensure that people using the service are kept safe from harm. 22 27 18 Staff must be sufficient quantity to meet the needs of the service including domestic and cooking duties. 12/11/2009 17/12/2009 16/12/2009 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that the needs of the people using the service are met at all times. 23 29 17 All persons employed by the service must have fully cleared enhanced Criminal Records Bureau checks in the name of the service where they are working. To ensure that the people using the service are kept safe from harm 24 30 18 Staff must receive training in Mental capacity Act and Deprivation of Liberty and Safeguards. To ensure that the people using the service are fully supported as required in their best interest. 25 31 8 The registered provider must provide an application to the Commission for the proposed registration of a manager. To ensure that the service has an appointed registered manager in post to lead and manage the service consistently. 26 33 23 A detailed and effect quality assurance systems must be in place to review the 23/12/2009 05/11/2009 17/12/2009 30/11/2009 Care Homes for Older People Page 37 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action service and the quality of acre being provided. This must be based on an action plan of improvements for the service. To ensure that the people using the service live in service that is able to continuously improve outcomes for individuals. 27 35 13 The service must ensure that were service users are unable to manage their own money that suitable safeguards are in place. To ensure that the individual is protected and that the service is supported and protected. . Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 30/12/2009 1 3 People using the service and or their representatives should sign the assessment and other documentation within the service regarding the provision of their care and support. The service should receive a copy of the social services assessment prior to admission. The service should ensure that the diverse needs of people are explored, recorded and appropriate action taken as required. The service should ensure that all paper work is fully completed, signed and dated if being used by the service. Page 38 of 40 2 3 3 4 4 7 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 5 9 The service should ensure that balances should be carried forward for medication that is used from one month to the next. The service should ensure that the activity board is up to date and accuratly displays what is avilable for people. The service should consider increasing the provision of active activity hours. The service should obtain more information regarding the provision of activities for the elderly. The service should provide a wider variety of stimulation and activity for the people using the service. The service should increase staffing numbers at peak times of the day. 6 7 8 9 10 12 12 12 12 27 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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