Inspection on 01/12/05 for St Marks Nursing Home

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Marks Nursing Home 07/02/07

St Marks Nursing Home 30/06/05

St Marks Nursing Home 03/03/05

St Marks Nursing Home 13/07/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Marks Nursing Home 145 Hylton Road Millfield Sunderland SR4 7YQ Lead Inspector Mrs P A Worley Unannounced Inspection 1st December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Marks Nursing Home Address 145 Hylton Road Millfield Sunderland SR4 7YQ 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) 0191 567 4321 0191 565 5834 Dr Lim Wyn Mrs. Pauline Jane Laverick Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (4) of places St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: St Marks Nursing Home is a purpose built home registered to accommodate up to 35 older people who require nursing care, including up to 4 with physical disabilities. There are 15 single bedrooms on the ground floor and 19 bedrooms on the first floor, one of which is a double room. A number of lounges and sitting areas are available including a designated smoking lounge on the first floor, and dining areas, which is situated within the lounges on the ground floor. En-suite facilities are not provided but there are adequate and accessible bathrooms and toilets situated around the Home. There are two floors that can be accessed by a passenger lift and stairs. The corridors and door widths allows easy access in and around the Home for wheelchair users. The home is situated slightly above ground level but can be easily accessed via a graduated ramp path. The home is located with very easy access to shops, community facilities and public transport, and within easy reach of the city centre. It is also within relatively easy reach of the seacoast. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out by one Inspector over one day. Twelve residents, the Manager, a number of nursing and care staff, the Domestic supervisor and three visiting relatives were spoken to. A sample of records were inspected that included, care plans and resident’s finance records of personal allowances, and staff files, complaints records and medication records. The building was checked to see the facilities and equipment available for residents, and the general maintenance and safety of the property. What the service does well: What has improved since the last inspection? Care plans have improved with use of new documentation and more detailed and relevant information is now recorded. The first floor smoking lounge has been decorated and a ventilation system put in to reduce the smell of cigarette smoke. The large ground floor lounge has also been decorated and new curtains and a new carpet were to be delivered within a day or two. Both areas are now brighter, fresher and offer a more welcoming and homely place for residents to live in. An outside contractor has been obtained to clean the large canopy above the ovens in the kitchen so that the kitchen staff are not now put at risk by climbing and stretching to clean it. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 6 The Manager looked at the domestic staff hours as suggested at the last inspection, so that care staff did not need to carry out domestic work. After consulting the staff, some changes to the shift times were made. These have been tried and have been found to be unsatisfactory to some staff and residents. However, the Manager is to have another look at them in order to make sure that a good standard service is still provided and staff and residents are satisfied. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed at this inspection. Key standard 3 was met at the last inspection and evidence was available to indicate that it continues to be met. Intermediate care is not provided by the Home. EVIDENCE: St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, & 9. Some good progress has been made with developing and improving the care plans. The health and personal care needs of residents recorded in their care plans adequately reflects their current levels of need, and guide staff as to how those needs are to be met. The systems in place for dealing with medicines are satisfactory and the arrangements ensure that resident’s medication needs are met. EVIDENCE: Care planning generally has improved and more recent plans have a better structure and are written in an easier to read style. A new care plan recording format has been developed and is still in the process of being implemented. A sample of care plans viewed showed that good assessment information was available and more detailed and specific information is documented in the care plans and daily records. Appropriate risk assessments are used and were up to date and the records better reflect residents’ health, personal and social needs and how they are met. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 10 Care staff and nursing staff were both knowledgeable about the care planning process and able to demonstrate verbally, the care provided in detail. This knowledge needs to be recorded in the plans to ensure a consistency of approach to care and dealing with and preventing situations. Work needs to continue with the developments of the care plans. Appropriate medication policies and procedures are available and include selfmedication. Drugs are ordered, stored and administered from an individual bottle/container system for each service user. A random check of the Medicine Administration Records (MAR) was made and was satisfactory, although the reason why medicines were not given or taken when the code ‘O’ (other) is used needs to be stated. Inspection of the ordering and storage arrangements and stock was satisfactory. An audit trail of some tablets was carried out and was satisfactory. In line with recent new legislation for the disposal of medicines the Home has an appropriate contract in place for the safe and appropriate disposal of medicines, including controlled drugs. A daily record is kept of the drug fridge temperatures. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14. Service users are encouraged and supported to lead lifestyles based on their preferences and choices. Links with families, friends and the community are maintained and service users are supported by staff in doing this. EVIDENCE: The homes’ philosophy encourages residents’ friends and families to visit and maintain links with them in the home according to their wishes. Evidence was seen of this during the day and visitors came at different times and spent time with residents as and where they chose to, and conversations with some residents and visiting relatives confirmed this to be normal practice. Some residents spoke of the shopping trip being arranged for them to do Christmas shopping and of forthcoming outings planned. One resident spoke of going out daily for a walk or wherever he chose, but came back for lunch because he said ‘he liked the meals here’. Other residents said they choose where their spend their time and what they do with it. All residents spoken with were consistent in their view that staff were helpful and supportive in this. Evidence was seen from observations, of staff asking residents what they wished to do, where they wished to go, and of generally offering choices to them on various matters throughout the day. Residents were also observed St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 12 coming and going as they chose and were able, and generally doing things to suit their individual preferences. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. A suitable complaints procedure is in place and is made known to residents and relatives. Residents and relatives feel confident that complaints would be listened to and acted upon appropriately. EVIDENCE: A procedure is available and is displayed in the home, which gives clear information about how, and who complaints can be made to. The information is also held in the policy file and is in the Service Users Guide. The records of complaints were inspected and found to be satisfactory although very few complaints are documented as comments and concerns raised are generally dealt with at the time or discussed at residents’ meetings. Residents and visiting relatives who were asked said that they were aware of how and who to make complaints to, and felt confident to do so if it was necessary. One relative said she had spoken to the Manager about the health condition of her relative and felt that some staff didn’t fully understand it, and the Manager had arranged further training for staff to address this, which the relative said was acceptable. This training was confirmed by the nursing staff. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 24. Communal facilities are provided for residents that are safe, comfortable and attractive, and allow easy access throughout the Home. Residents’ bedrooms are comfortable and furnished with many of their own possessions, which gives them a personalised effect. EVIDENCE: The planned re-decoration and refurbishment of the Home has continued. The smoking lounge on the first floor has been decorated and a ventilation system provided, as previously recommended. The decoration of the large lounge on the ground floor with patio doors has recently been completed and a new carpet and curtains were scheduled for delivery during the week. Residents spoke with enthusiasm at the completion of the work being carried out in the room, as it is an attractive, bright and spacious room in which to spend time. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 15 All communal areas are clean, bright, attractive and homely in appearance, are tastefully decorated and furnished with co-ordinating furnishings and curtains, and are domestic and varied in style. Residents are encouraged to bring into the home personal items and furniture of their own. A number of rooms were viewed to confirm this as they were personalised to suit individuals. All were clean, odour free and generally well maintained. Additional shelving has been provided in one resident’s room in order to accommodate the many items accumulated from his hobby, which was appreciated by him and his relatives. In another room where the furniture has been moved to accommodate the residents’ own furniture and to allow more space, a glass cabinet is freestanding and also the wardrobes, as they have been moved. Both need to be secured to the wall to prevent the risk of them falling over and causing an accident. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Staffing numbers and skill mix are appropriate to the assessed needs of residents and ensures that at all times residents are supported and are in safe hands, by an experienced group of staff. A well-trained staff team have the appropriate qualifications, and continue to receive relevant training to enable them to carry out their work competently. The procedures for the recruitment of staff are satisfactory and provide the safeguards to offer protection to people living in the Home. EVIDENCE: Examination of the staff rotas confirmed that adequate qualified and care staff are provided at all times to meet the needs of the residents. Rotas are completed for the weeks up to January 2006 and showed appropriate staffing numbers to be allocated. Residents who were spoken with said staff were always available to see to their needs and some comments received from residents were, “the staff are all good”, “I couldn’t ask for better staff” and “some’s better than others, but they all look after me”. Ancillary staff are in post to support the care service and the recommendation made at the last inspection to review the domestic staff shifts has been carried out. Monitoring of the domestic service since the change in shifts has indicated to the Domestic Supervisor, and some residents that it is not St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 17 satisfactory and the Manager said she is to further review the shift patterns in order to maintain an appropriate service that satisfies the staff involved, and the residents. Some staff who were spoken to demonstrated a good knowledge of residents needs and how they were met and confirmed that they received training to enable them to carry out their work effectively. A staff training and development programme is in place to cover induction training, statutory training and other training relevant to the care offered in the Home. Only the more recently appointed care staff do not have the NVQ Level 2 qualification, and the other existing care staff who have the qualification are in the process of or will undertake NVQ Level 3 training. Evidence was seen in the training programme of the opportunities for staff training and staff files staff training files, and conversations with staff confirmed that good levels of training opportunities are offered. Training includes specific conditions and care needs. The required statutory training is provided to include moving and handling, fire safety, food hygiene, infection control and Control of Substances Hazardous to Health (COSSH). Inspection of three staff files of one nurse and two care assistants was carried out. The contents confirmed that appropriate checks are carried out prior to staff taking up post that includes Criminal Records Bureau (CRB) and POVA register checks, and of two written references being obtained. Evidence was also seen of induction training for new staff. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. The Manager is appropriately qualified and has extensive experience in care and related management, to competently run the home and service. Some systems are in place to determine the quality of the service provided by the Home, and ensure that it is run in the best interests of the residents. Appropriate systems are in place and function well, to safeguard service user’s personal allowances. Records are clear and well documented. Staff follow appropriate safe working practices to promote and protect service users’ health, welfare and safety. EVIDENCE: St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 19 The Registered Manager has the appropriate nurse qualifications and experience to manage the home. She has completed the Registered Manager’s Award training, and is currently undertaking an advanced health and safety training course. A Deputy Manager is also a Registered General Nurse (RGN) and supports the management functions of the Home. Some quality monitoring systems are in place but no formal or structured system of quality assurance. Service monitoring includes resident questionnaires, residents meetings, staff meetings. Outcomes from surveys are made known in the home’s newsletter. The notes of residents meetings were displayed in the home for information. The activities co-ordinator has set up group meetings to include residents and relatives, and staff from all disciplines. Audits of medicines are carried out and complaints and concerns, and falls and accidents are monitored. The Provider makes regular visits to the Home, and monthly reports are submitted to the Commission as required by the Care Homes Regulations 2001, Regulation 26, of the conduct of the Home. Inspections are responded to appropriately, and policies and procedures and practices are reviewed as required. The majority of residents have their personal allowances held by the Home that are usually dealt with by the Administrator, however she had been on maternity leave for some months and they have been dealt with by the Manager in her absence. Each service user has an individual record of all accounts and transactions, with numbered receipts to support them where necessary. Two signatures are obtained for all transactions. One resident has a large amount of money in safekeeping, which has accumulated from personal allowances sent to the Home by the Social Services appointee who deals with this resident’s money. The Homes insurance does not cover the amount and the Manager was advised to contact Social Services to discuss alternative arrangements for its safekeeping. No one in the Home is an appointee for residents’ monies’, the majority of appointees are families. The records of residents personal allowance transactions showed that they were well kept and clear, and individual records of accounts were maintained. It was recommended however, that individual receipts from the hairdresser and chiropodist be obtained as currently all resident’s names and costs are on one collective list. A random check of records against monies held showed them to be accurate. In conversations, staff confirmed that they receive training in all areas of health and safety. Throughout the day staff demonstrated awareness of good health and safety practice. Moving and handling procedures by staff with the residents, were observed to be satisfactory with appropriate practices carried out. Self-closure ‘Dorgards’ were in place and used appropriately where St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 20 bedroom doors were kept open when rooms were occupied. No hazards were identified at this inspection. The risk of accident posed to kitchen staff by cleaning the large kitchen canopy over the cookers, was raised at the last inspection and was considered hazardous. The Manager has now got an external service contract arrangement for the canopy to be cleaned monthly, which removes that risk to the staff. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 x x x 3 x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13(4) Requirement Freestanding wardrobes and cabinets with glass must be secured to prevent the risk of accidents. Timescale for action 12/12/05 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. 2. Refer to Standard OP7 OP33 Good Practice Recommendations The Manager should continue with the development of the care plans in order to progress the improvements already made in the documentation process. The manager should consider a more structured quality monitoring system to ensure an effective service is given by the Home. St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Marks Nursing Home DS0000018197.V254030.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!