CARE HOME ADULTS 18-65
St Marks House Brook Street Lye Stourbridge West Midlands DY9 8SE Lead Inspector
Mrs Jean Edwards Key Unannounced Inspection 15 November 2006 08:40 St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 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 Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 House DS0000025028.V317778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Marks House Address Brook Street Lye Stourbridge West Midlands DY9 8SE 01384 896654 NONE 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) Chadd Housing Association Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Old age, not falling within any of places other category (9) St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 9 OP and up to 16 MD Date of last inspection Brief Description of the Service: St Marks House is a purpose built home, opened 17 years ago, owned and supported by the Church Housing Association of Dudley & District (CHADD). It is located in Lye, in an area which is part residential and part light industry. There are local amenities nearby and the Home is within walking distance of several good bus services to nearby towns. The frontage of the Home has ample car-parking facilities; to the rear there are well-maintained gardens, with mature trees, shrubs, flowerbeds and patio areas. The interior of the Home appears bright and airy, with domestic and Homely fixtures and fittings. The Home provides 16 single en suite bedrooms for people over 50 years of age, who have various forms of mental ill health. The Home provides four bathing / showering facilities, which are satisfactory to meet the amended National Minimum Standards for Younger Adults. There are a number of seating areas around the Home including a well-used conservatory extension, a quiet room and designated smoking lounge. The Home has a stable staff team of 23 people including the acting manager. The fee at this home is £323.00 per week for everyone. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection has been conducted by an Inspector from the Commission for Social Care Inspection and has taken place over one weekday between 8:40 a.m. and 5:20 p.m. The purpose of the inspection visits has been to assess progress towards meeting the Care Homes Regulations 2001 and National Minimum Standards for Younger Adults. The range of inspection methods used to obtain evidence and make judgements includes discussions with the manager, assistant managers, seniors and other staff on duty. There has been contact with professionals associated with the home and discussions with the majority of residents living at the home. A number of records and documents have been examined. Other information was gathered prior to the inspection visit, from reports of visits undertaken by the organisations representative and pre inspection questionnaire submitted by the home. Sixteen service user surveys were sent to the home by the CSCI and an analysis of the 15 copies of survey forms returned is contained throughout this report. Comments have been very positive about the home, meals and staff. What the service does well:
The organisation has responded to the previous inspection report from 30 November 2005 with a comprehensive action plan, giving dates for the required improvements to be put into place. The majority of required improvements are in place. CHADD is a forward thinking organisation, with plans to install an internet connection at the home and air conditioning before the warm weather next summer. Residents are provided with good clear information about the service they can expect from St Marks. The results of the CSCI service user survey indicate the majority of residents say they received enough information about the home before they moved in, one person states, they gave me quite a lot of details and information about life at St Marks House, and the details and information I found to be very impressive, and it appeared to have a good name for itself. Fourteen out of fifteen residents state they have received a contract with terms and conditions. A resident commented, I read the contract when first admitted to St Marks Residents are encouraged to treat St Marks as their own home and they can be as independent as they wish. Residents can make their own choices and have their own meetings. Notes of the meetings can be seen on the resident’s notice board. A range of topics is discussed, with opinions freely aired about the
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 6 running of the home. The topics at a recent meeting included the plans for Christmas and household matters. Residents are able to go on an annual holiday if they wish and 4 residents opted to go to Blackpool in October, they enjoyed a wonderful, warm day. To the CSCI survey question: Are there activities arranged by the home that you can take part in? The responses are always 5, usually 9, sometimes 1, with the comment, usually I can participate in most activities arranged by St Marks house i.e. board games, (such as Hangman - which makes ones brain work intellectual game), handicrafts i.e. crocheting, pub lunches, outings, Holliday annual holiday or I might on the odd occasion go on a shopping trip with staff and residents, although I normally shop by myself. Arrangements for the Christmas celebrations are well advanced. A Christmas fayre is going to take place on 2 December 2006 with some residents taking flyers to local shops and neighbours and flyers are also sent to relatives. Some residents like to help out on stalls at the fayre and they are involved in other events such as Christmas card writing, calendar making and cooking sessions. Menus at St Marks are varied with nutritious options. The home has achieved the Silver Award for healthy eating from Dudley Environmental Services and NHS trust. Residents have been complimentary about the food during this visit and the responses to the CSCI service user survey question: Do you like the meals at the home? Always 9, usually 4, and sometimes 2, with comments, I enjoy a good majority of the meals at St Marks, as we always have a very varied menu weekly, and that it is available to make our own choice from the weekly menu, with plenty of choice. St Marks continues to have a stable group of staff who have worked at the home for a long time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts, especially to support residents with fund raising and leisure time activities. The home follows a rigorous system to select and recruit new staff and this provides excellent safeguards for residents. There is a warm and friendly relationship between staff and residents, with lots of friendly interaction during the visit. Members of staff continue to demonstrate a dedicated approach to their work, with a good knowledge of residents’ needs, likes and dislikes. The organisation has a strong commitment to staff training and development, demonstrated by an exceptional ratio of 94 of care staff with at least an NVQ level 2 award in care and the remaining staff registered as candidates to achieve the award. St Mark’s continues to maintain excellent standards of cleanliness. The home is tidy, homely and comfortable. Although the home does not employ domestic staff everyone including the manager is involved in cleaning duties. Residents state that the standard of cleaning is very good and they are generally pleased
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 7 to be involved in daily tasks, especially their own bedrooms, seeing this as a way to keep their independence. The residents responded as follows to the CSCI service user survey question: Is the home fresh and clean? Always 13, usually 2 and one person commented, St Marks house has got an extremely high standard of cleanliness throughout the entire home. This inspection has been conducted with full co-operation of the Manager, staff and residents. The atmosphere through out the inspection has been relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? What they could do better:
The home needs to record each residents cultural or spiritual preferences and as part of their individual plan. For residents with diabetes, their care plans must include guidance as to their skin care, foot care, eye care and monitoring arrangements with specialist health care professionals such as diabetic nurses, or diabetic clinics. The home must also keep records that residents are offered regular dental checks. The home must assist the resident with increasing hearing loss, to make contact with the sensory disability team in Dudley to help her with the request to learn a suitable sign language technique. Any known risks must also be assessed and where possible minimised; these need to include changes in behaviour such as self harming or undressing in public. The home must also ensure any written information about a resident is recorded and stored in compliance with the Data Protection Act 1998. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 8 Although the homes system for managing residents medication is generally satisfactory, a procedural and practical improvement must be put in place if the staff are to take on nursing tasks, such as giving suppositories. Staff training must be provided with guidance from the GP and district nurses as back up for intrusive procedures. There are a small number of minor repairs and renovations identified at this visit, which need to be added to the homes maintenance programme and completed as soon as possible. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Quality in this outcome area is good. There is good evidence that all residents needs are assessed and reviewed, with multi-disciplinary health care professionals. The home offers good, clear information about the service, including updated residents contracts / terms and conditions of occupancy. This has the effect that residents and their advocates have sufficient information regarding their rights and entitlements and any agreed restrictions. The home actively encourages introductory visits and there is documentary evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Marks House has clear information to help residents understand what services the home can provide, in addition to the service user guide, all residents are given a copy of the staff key worker handbook, and their rights and expectations are discussed in ways, which are meaningful to them. The home has a clear admission criteria and the admission of new residents is only agreed after a summary of the care management assessment and a copy of the care plan has been received. The age range for admission is over 50
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 11 years of age and the manager or assistant manager has undertaken a full needs assessment to ensure the home can meet the persons assessed mental health needs. From discussions and examination of a sample of recent new admissions to the home there is good evidence that the assessment is conducted professionally and sensitively and involves the resident, and their family or representative, where appropriate. The sample of residents files the home has comprehensive assessment information and there is evidence of periodic reassessment, which is good practice. In addition the manager seeks reviews and reassessments for any resident with changing needs. An example is a current resident with changes to behaviour patterns, with attempts to disrobe in public areas, and display aggression towards staff at times, which is unusual. Discussions with staff and examination of documentation provide evidence that specialist services have been accessed. It is evident that the manager only agrees to admissions if she is confident that the staff team have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Examination of records and discussions with staff and residents confirm that prospective residents are given the opportunity to spend time in the home. The home allocates a member of staff to give information and to help the person understand how the home is organised and run and explain what facilities and services are available. Throughout this visit the members of staff have been seen to be communicating effectively with the residents, with banter where appropriate. The sample of residents case files examined demonstrate that residents are provided with a Contract / Terms and Conditions, which sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident in an easy to understand format. The organisation demonstrates good practice making sure that the contract / terms and conditions are reviewed on a regular basis and reflect good practice guidance, for example from the Office of Fair Trading. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good The care planning system continues to improve and generally provides staff with the information they need to meet each person’s needs. The home plans to develop a more person centred approach to the planning process so that residents have as much control as possible over their lifestyle and care. Risk assessments continue to be expanded to cover all aspects of personal and social, and health care; this improves protection for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is evidence that all residents have a care plan in place. During discussions with residents they confirm that they have active involvement in developing and implementing their own care plan. This reflects their preferred lifestyle and routines, such as spending time alone or going out unaccompanied. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 13 The home continues to have a comprehensive risk assessment system in place for each person. The documented risk assessments are colour-coded for each area of risk. Examples are the risks of living on the first floor (Green), going out unaccompanied (gold), self-medication (pink), smoking (yellow). From the sample of residents care examined it is noted that there are additional risks associated with two residents, which currently do not have written risk assessments in place. Both have been at risk of self-harming and this must be taken in to account on an on-going basis. One person has changes to behaviour patterns, which have not been formally risk assessed and staff must be provided with written guidance to manage unexpected aggression directed to them and behaviour such as attempting to undress inappropriately. Although residents notes assessed generally contain fuller details of the care offered, further expansion is required to reflect how goals and care needs identified in the care plan are evaluated. The progress reports are not completed daily, however there are personal details of daily care and events relating to residents in a diary used for staff communication. This method of recording does not comply with the Data Protection Act, which requires that all personal and sensitive information is held and stored confidentially and securely for each subject (person). Residents continue to take an active role in the running of the home, they are regularly consulted about all aspects of their lives through care planning reviews, formal reviews, regular residents meetings and surveys. The home has good documentary evidences of the outcomes and decisions agreed with residents. The home has a comprehensive system for managing residents finances, which is well established and is regularly audited by members of the CHADD committee. A random sample of balances and records of transactions of residents finances held in temporary safekeeping by the home is satisfactory, with two signatures and receipts for each transaction. The appointeeship for a small number of residents without family support, held by the previous registered manager, has transferred to the acting manager, who has applied to be registered with the CSCI. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. Links with the community are generally good and planned and spontaneous activities take place. Residents are generally able to take advantage of and develop socially stimulating opportunities, including holidays away from the home. The menus are designed to consistently offer residents choices of healthy and good quality meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of residents were at home at some times during this inspection visit. One person is on home leave visiting a parent, other left the home during the visit to go shopping, or other personal pursuits. A resident states she enjoys her independence, going out unaccompanied, visiting churches, social centres, charity venues and using public transport. Other residents have
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 15 been observed making their own drinks and taking responsibility for household tasks, some with support from staff. Some of the residents have had an annual holiday away from the home, funded as usual from the budget at St Marks and CHADD. Five residents accompanied by staff took a day trip to Blackpool in October, and enjoyed a wonderful warm day. The home has a structured activities programme, discussed with the residents and generally organised and led by members of staff. Stimulating and challenging board games and quizzes continue to be among favourites. In discussions with staff they demonstrate awareness that some people prefer not to participate in structured activities but may need support with individual leisure pursuits. One resident has hand made all of her Christmas cards, which are ready and waiting to be sent or given out. The residents have decided to have a Christmas meal at a local venue Hadcroft in Lye. Everyone has made their choice from the three course menu. There is a visiting policy, which is displayed in the home. Visitors can be received in private in residents’ bedrooms and in the quiet areas of the home. Discussions with the residents and examination of a sample of records indicate that every effort is made to promote positive relationships with family members, friendships in the wider community. Each person has a varying amount of contact with family and friends, with details of any additional support recorded in case files. Each person has details of advocacy services available in the key worker handbook and there is signed evidence of receipt of this document on each persons file. The manager and staff make great efforts to ensure that meal times are social occasions and a member of staff sits at each table to have the meal with the residents. Menus are displayed and meal choices are made for the forthcoming week as a Saturday morning activity, though people can and do change their options at times. Special attention is given to try to encourage anyone with a poor appetite to eat. There is evidence that advice has been sought for a resident who is currently refusing meals and food supplements. The kitchen staff are experienced and knowledgeable about residents dietary need and makes sure that they are able to enjoy the food they prefer and like. The home has started to introduce tasting sessions, which include a variety of dishes that encourage residents to try new and sometimes unfamiliar food. Residents are generally complimentary about the food, saying there is always plenty to eat and lots to choose from. Fresh fruit, hot and cold drinks are readily available in the conservatory area. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. The health needs of residents are well met with generally good evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During discussion staff have shown that they have awareness and understanding of principles of offering personal support and are responsive to the varied and individual requirements of the residents. They recognise that the delivery of personal care is highly individual and has to be flexible and reliable. Staff know that they need to be sensitive and attention is given to ensuring privacy and dignity when providing personal care for residents. Whenever possible residents are able to have choice about which staff provide their personal care and the residents are supported to be independent and responsible for their own personal hygiene and personal care, wherever it is possible for them to do so.
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 17 The home continues to encourage and support residents to attend screening programmes such as well person checks. Each person has their preferred option of dentist, optician and chiropody service. There is evidence that staff are allocated to work extra hours to their usual rota, to act as escorts for residents to attend appointments. One of the assistant managers acted as an escort of one of the residents to attend a dental appointment, at the end of his shift on the day of this inspection visit. One of the older residents, identified as being at risk of poor nutrition, previously referred to the community dietician has food charts to record and monitor food and fluid intake, with positive results. The home has comprehensive medication policies and procedures and all staff administering medication have received accredited medication training. The home currently uses a nomad dosage system from a local pharmacy but is planning to change to MDS (Monitored Dosage System) from a larger supplier. It is very positive that 50 of the residents administer their own medication, with support and agreed monitoring. A number of small improvements have been introduced as a result of advice given at the previous visit. The home has obtained an up-to-date BNF and clarified as directed dosages of medication to have clear instructions for administration. It has been noted at this visit that a GP has prescribed rectal suppositories for one resident and given staff advice that they may undertake this invasive body procedure. One dose has been given. The home does not have written consent from the GP, district nurse or the resident or their representative. There are no written procedures, protocols or staff training in place to ensure that this procedure is undertaken safely and competently. The manager needs to seek the required permissions, staff training and devise agreed written guidance if the home wishes to take on the responsibility for this procedure. Staff have good access to training in health care matters and are encouraged and given time to attend seminars and lectures arranged by local health care organisations on specialist areas of work. The home has revised and expanded the policy and procedural guidance for staff relating to dying and death to take account of relevant cultural customs for faiths other than the Christian faith. Records of discussions held with the next of kin of the older person who is Muslim and the home is now aware of observances and practices for this person. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. The home has a comprehensive complaints system with some evidence that staff understand the need to listen and to act upon areas of concern. Policies, procedures, guidance and staff training are in the process of implementation in order to provide residents with safeguards from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a satisfactory complaints procedure, which is displayed in the reception and is contained in the service users guide and key worker hand book, which is given to each resident. The pre inspection information from the home indicated that an anonymous complaint was received, which is recorded in the home’s complaints log, with satisfactory evidence of the investigation and findings. There was no evidence to substantiate the complaint. Residents feel that they can raise any concerns either through their meetings or directly with the manager or staff at the home. The home has a copy of the local authority multidisciplinary procedure for the protection of vulnerable adults: Safeguard & Protect. Discussions with staff indicate that they are aware of the homes procedures to safeguard residents and the local authority multidisciplinary procedure for the protection of vulnerable adults and there are staff signatures to evidence that all staff have read and have an awareness of policies to protect vulnerable adults. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 19 The home has good policies and procedures in place to protect residents finances managed by the organisation or held in temporary safekeeping at the home. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Quality in this outcome area is excellent. The standard of the décor within this home is exceptionally good with evidence of improvement through ongoing maintenance. The home generally presents as a safe, homely and comfortable environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Marks House provides accommodation for up to 16 adults over the age of 50 years with mental ill health. Residents may stay at the home for their lifetime as long as their needs can be met. The premises currently comprise a purpose built two storey house with spacious communal areas and 16 en suite attractive bedrooms. During the tour of the premises there is evidence that the home continues to be maintained to very high standards on an ongoing basis. There is evidence of improvements and planned refurbishments, which demonstrate the active involvement of residents living there with their choice of decor. The quiet
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 21 lounge on the first floor has sky TV and a new DVD player, which is enjoyed by a number of residents who regularly watch sports programmes. There is also an appealing quiet area on the first floor with comfortable chairs, occasional table and book case with a wide range of books. There are a small number of minor repairs needed, which are now included on the reactive maintenance programme and will soon be actioned by the organisation. The kitchen has recently been inspected by Dudley MBC Environmental services and it is stated that there are no recommendations. The kitchen is well organised, with well maintained equipment, and a wide range of food stocks stored and prepared in good compliance with food safety. The homes laundry service continues to be well organised and the staff achieve good standards of infection control. There is a laundry procedure and measures are in place for supplies of disposable gloves and aprons to be readily available in the laundry at all times. Throughout the home good standards of cleanliness continue to be maintained and there have been no discernable malodours during this visit. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is excellent. The home has a stable, enthusiastic, well-motivated staff team and the organisation continues to demonstrate a strong commitment to staff training and development to ensure residents receive consistent assistance and support to develop their potential. There are rigorous staff recruitment processes, which provide good safeguards for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a stable staff team at St Marks House, with 1 resignation of the assistant cook and retirement of the registered manager since the last inspection in November 2005. From assessment of the pre-inspection information, staffing rotas and discussions with the manager it is indicated that staffing levels are satisfactory. During discussions staff have shown that they are aware of the aims, policies and procedures of the home. It is evident that members of staff have a good rapport with residents and are knowledgeable about their needs and
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 23 preferences. The newly appointed assistant manager indicates he has very positives impressions of the care at St Marks. A random sample of staff files assessed at this visit demonstrates satisfactory recruitment practice, with very well ordered staff files and comprehensive documentation. The manager has agreed to provide the missing photograph for the assistant cook, recruited 22 May 2006. The organisation continues to demonstrate a strong commitment to staff training and development and is sourcing and providing all staff with appropriate training to raise awareness and skills to respond to residents changing needs. The home currently has a commendable ratio of 94 of care staff with an NVQ level 2 care award, with new candidates registered for training. All staff have an annual appraisal and there is a formal structured supervision system, with evidence that care staff have receive a minimum of 6 one-to-one supervision meetings. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is good. The acting manager is supported well by staff in providing clear leadership throughout the home with people demonstrating an awareness of their role and responsibilities. The systems for resident consultation at St Marks are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. The compliance with all aspects of records and health and safety is satisfactory, which minimises potential of risks residents safety and well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Kath Rhooms was appointed manager for St Marks in August 2006 and her application to be registered with the CSCI is being processed by the Central Registration Team. She has worked at St Marks house for 13 years as assistant
St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 25 manager and has valuable experience in assisting the development and running the service. She has also worked in a management role in a hospital setting for people with mental illnesses. She is currently undertaking the Registered Managers Award (RMA), due for completion in June 2007. She also continues to update her professional development and she attends and participates in workshops. The home is in the process of implementing a quality assurance system to audit the home across the National Minimum Standards for Younger Adults and it continues to hold accredited Investors in People Award. The home has an annual development plan, which reflects recent improvements, actions for the current year and plans for expenditure and staff development for the forthcoming year. There are also a number of other monitoring arrangements in place including unannounced monthly visits from the committee members, with comprehensive reports, which are given to the home and copied to the CSCI. During discussions with residents and staff it is evident that the management style at St Marks is open, approachable and supportive. St Marks has good arrangements in place to ensure that residents are consulted about the day-today running of the home. There are regular and recorded residents meetings, with a wide range of topics discussed about the running of the home and future plans. The regular residents feedback questionnaires circulated in September 2006 have been collated and published. Relatives and wider stakeholders surveys about the homes performance have also been circulated in September 2006, with collated results published. The sample of mandatory staff training records, fire safety and maintenance service records examined are generally satisfactory. Accident records have been examined and there is evidence that the manager undertakes a regular documented accident analysis. There is evidence that one person who has had 7 falls has been referred to an occupational therapist and falls team and is now been supported to do daily exercises. There are a total of 14 - recorded accidents involving residents and 1 accident involving staff since the last inspection visit in November 2005. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 3 2 X 2 2 X St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 12(1) 15(1) Requirement 1) To ensure each residents cultural / spiritual preferences and needs are recorded in their individual plan 2) To expand the care plans for residents with Diabetes to include guidance as to their skin care, foot care, eye care and monitoring arrangements with specialist health care professionals such as diabetic nurses, clinics etc. 2 YA9 13(4) To expand individual residents 01/01/07 risk assessments to take account of areas such as potential for self harm, disrobing, changing behaviour which present challenges to staff or other residents, as needed To undertake appropriate age 01/12/06 related health screening assessments for any older residents potentially at risk, such as a documented nutrition screening tool and tissue viability assessment (Timescale
DS0000025028.V317778.R01.S.doc Version 5.2 Page 28 Timescale for action 01/01/07 3 YA19 13(1)(4) St Marks House of 01/02/06 Not Fully Met) 4 YA19 13(1)(4) To ensure that all residents are offered a regular (at least annual) dental check up with refusals recorded 01/01/07 5 YA20 13(2) 1) To review the medication 01/12/06 policy and practices ensuring that if staff are to undertake such procedures as the invasive body procedure of administering rectal suppositories the following are in place - That written consent is obtained from the resident (where there is capacity) or representative and the GP for this procedure to be undertaken by care staff - A written procedure and protocol is in place, ratified in writing by the district nurses and GP - Training for named staff is in place, and that they are assessed as competent by the district nurse / trainer - Implement a protocol to ensure that there are contingency arrangements to ensure that there are trained staff available at the home each day or agreement that the district nurses will undertake the procedure - Clarify with the homes Insurance Company that this procedure is acceptable 2) To provide written guidance in care plans for any PRN medication. St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 29 6 YA26 23(2) To undertake minor renovation and redecoration to the damaged paintwork on the en suite door in NJs bedroom - In Progress (Timescale of 01/02/06 Not Fully Met) 01/01/07 7 YA26 23(2) To ensure that the minor repairs 01/02/07 and renovations identified at this visit are recorded on the reactive maintenance programme and rectified To cease to record residents 01/12/06 personal or sensitive information in the office diary and ensure that information is recorded and stored in compliance with the Data Protection Act 1998 01/01/07 To contact Environmental Services to seek their view of the training risk management provided from the training provider, without accreditation, taking action in accordance with advice - Partly Met (Timescale of 31/07/06 Not Fully Met) To contact the training provider as advised by Environmental Services requesting details of her qualifications and any accreditation or approved status 8 YA41 17(1) 9 YA42 13(4) 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 YA19 Good Practice Recommendations That the dates of visits are included in the residents record of doctors visits
DS0000025028.V317778.R01.S.doc Version 5.2 Page 30 St Marks House 2. YA19 That a referral is made to the sensory disability services for the resident with increasing hearing loss, to facilitate her learning a suitable signing technique or other means of communication St Marks House DS0000025028.V317778.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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