Inspection on 10/03/08 for St. Marks Nursing Home

This inspection was carried out on 10th March 2008.

CSCI found this care home to be providing an Good service.

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 07/12/06

St. Marks Nursing Home 10/11/05

St. Marks Nursing Home 24/05/05

St. Marks Nursing Home 22/11/04

St. Marks Nursing Home 14/06/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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 1 Hartburn Lane Hartburn Stockton-on-Tees TS18 3QJ Lead Inspector Val Daly Key Unannounced Inspection 10 March 2008 09:30 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 DS0000000206.V354173.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 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 DS0000000206.V354173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St. Marks Nursing Home Address 1 Hartburn Lane Hartburn Stockton-on-Tees TS18 3QJ 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) 01642 670777 01642 671365 sherwinb@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Natalie Melling Care Home 39 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental disorder, excluding learning of places disability or dementia (0) St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age category for individuals with dementia or mental disorder is aged 60 7th December 2006 Date of last inspection Brief Description of the Service: St Marks is situated between Stockton and Eaglescliffe and is within easy reach of shops, parks and other amenities. It is a modern purpose built home in its own grounds. The home has been designed to provide care to elderly people, mainly with an Alzheimers diagnosis and other dementia related conditions and also older people with mental health disorders. The accommodation is on two floors, accessed by a lift and provides a choice of lounge and dining areas. There is also an enclosed patio garden at the rear of the home, which is accessible from the ground floor lounge. The weekly fees at St Marks range between £353 to £587. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was a key unannounced inspection and was completed by an inspector in two inspection days. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A number of records were looked at including assessments of people who use the service and plans of care, staff recruitment records, complaints and maintenance records along with the annual quality assurance assessment. People who use the service, two members of care staff, the activities Co-ordinator, the administrator and the manager, were engaged in discussion about living at St Marks. The manager had completed an Annual Quality Assurance Assessment prior to the inspection. The AQAA is the services self-assessment of how they think they are meeting the National Minimum Standards. This information is received prior to the inspection and it is then used as part of the inspection process. On the day of the visit the manager and administrator provided the information and documentation required. The Commission for Social Care Inspection sent ten surveys to the home for people who use the service to complete. Four were completed and returned. Comments received can be read within the report. This was a positive inspection; people were open and friendly and welcomed discussion about the home. What the service does well: St Marks provides a clean, pleasant and well-maintained home for people to live. Staffs work well together as a team to provide the people who use the service with a comfortable and homely environment, offering a good standard of care. Each person who wishes to use the service has their care needs assessed prior to their admission to ensure they can be met. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 6 A high number of carers have achieved NVQ level 2 or above in care and this training is ongoing for more carers. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 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 DS0000000206.V354173.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 6 People who use the service experience excellent 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 have their needs assessed. EVIDENCE: Since the previous inspection the manager has produced a service user’s guide and updated the statement of purpose. Both documents are detailed and informative. Each person who wishes to use the service has their care needs assessed prior to their admission to ensure they can be met. The documentation is person centred and the areas covered are; communication, lifestyle, maintaining a safe environment, mental state and cognition, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, sleeping, pain, medication, end of life arrangements, any personal needs and expectations or medical conditions, St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 9 activities including comments from the person and showed evidence of their or relative involvement. A map of the person’s life is included, showing their younger life, where they lived, employment, children, hobbies and interests. The home does not provide intermediate care. A comment in a survey was ‘I came on a visit and liked the atmosphere and staff immediately’ St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The files of four people who use the service were examined. Since the previous inspection improvements in this area had continued. Following on from the assessment an individual care plan is formulated where there is a health, social or personal need. The plans were reviewed regularly and showed involvement from relatives. There was documentation to demonstrate that the health care needs of people using the service were being met with general practitioners and consultants being involved. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 11 There was also detailed information in ‘ a day in the life of’ which gave information of any special needs, for one person about eating and how to assist them. There were risk assessments in place where required, nutrition, safe bathing, moving and handling and two people had a sleep chart in place as they were unsettled at night. All accidents are recorded, and the manager then completes a monthly analysis matrix. This information is then sent to Head Office, three monthly to show increases/decreases and what has been put in place for prevention. Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication and regular auditing is carried out. Since the previous inspection one member of staff has undertaken additional training in the current legislation regarding medication. At the time of the inspection there were no people, who managed their own medication. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their lifestyle. A variety of food is offered. EVIDENCE: The home employs an activities co-ordinator who whilst fairly new to the post is very keen to provide activities, which the people who use the service will enjoy. The manager said that further training for the activities organiser had been arranged for later in the year. At the time of the inspection information regarding who took part in the activities and how they responded was kept in the activity person’s own book. During discussion he said that this information would be put in individual care plans and time had been put aside to complete this task. The organisation has a manual of guidance of activities, which is broken down into the seasons of the year. The home has a weekly activity programme in place, which is flexible for the needs and wishes of the people who use the service. At the time of the St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 13 inspection people were enjoying ‘motivation group work’, finishing off proverbs and taking part in a quiz. Other activities include a weekly cinema club, sports competitions, reminiscence, crafts, baking scones/cakes in the reminiscence kitchen area and one to one chatting. A comment in a survey was ‘Staff are always interacting with residents. They are aware of individual needs and treat each person as an individual’, ‘my family member cannot partake in activities but likes the music on Thursdays’. Discussion took place with the cook about the menus and the timing of meals. The cook said she enjoyed all the home baking she was doing, which also seemed to be appreciated by people in the home. The menus showed a variety of food being offered, and they are checked for their nutritional content. People who use the service have their main meal at teatime and a lighter meal at lunchtime. There are two choices for each meal with more alternatives offered along with any special diets. Where people are not able to choose their food from the menu they are shown the meals to enable them to choose at the time of serving. There is a an extra menu now in place ‘night bite’ which gives people a range of choices of food they can have in the evening and during the night. This menu is in poster format and a picture flip chart to assist choice. The cook said she obtains information of people’s likes and dislikes from relatives and also checks the wastage of food, which may indicate a change to the menu may be needed. A comment in a survey was ‘My family member is eating well now and enjoys his food’. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain and the home has an appropriate procedure in place. Training for staff in adult protection has taken place, keeping people who use the service safeguarded. EVIDENCE: The home has a complaints policy and procedure in place. This has been updated since the previous inspection and includes the Contracts and Commissioning department of the Local Authority. There had been two complaints received at the home since the previous inspection. Records showed that they were investigated promptly and there were written reports of action taken in place. Following the outcome of the investigation complainant is asked if they are satisfied or not. The manager holds a monthly resident forum for people who use the service, their friends and relatives and any concerns or grumbles can de discussed. Relatives can also make an appointment to see the manager at a time to suit them. A comment in a survey was ‘ There are a number of staff I can speak to but I have not felt the need, the care has been excellent’. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 15 The home has a whistle blowing policy and an adult protection policy in place. Since the previous inspection there was evidence in the staff training files to show that staff had received training in ‘Adult Protection’. During interviews with three members of staff they confirmed they had received training and were aware of the procedure to follow in the case of suspected abuse. Where people who use the service lack capacity a named relative is identified. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. St Marks is comfortable, homely and well maintained. EVIDENCE: A tour of the premises took place and all areas were comfortable and well maintained. Since the previous inspection the reception area had been redecorated making it a welcoming space. A bathroom had been re furbished and upstairs new flooring was in place in the communal area creating a distinct dining and lounge area. People’s bedrooms are homely and contained personal possessions. There was a ‘memory box’ outside each bedroom, for small items, which had important to the person. Each bedroom door has a lock keys are given to relatives on St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 17 request. On the ground floor, in front of the kitchen there was a baking reminiscence area, which people enjoyed using as a small group or individually looking at and discussing packets and tins of products they used to use at home. At the time of the visit work was underway to provide a sensory room on the first floor along with n office for nursing staff. The home was extremely clean and odour free. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The vetting and recruitment practices are robust. Staffs is trained and qualified and relevant information that safeguards people who use the service is in place. EVIDENCE: The home has a rota in place, which shows a skill mix of staff being on duty on each shift. Since the previous inspection the home has more staff with the appropriate qualifications. The home has a robust policy and procedure in place for the recruitment of staff and on examining four staff files it was evident that they were being followed. The staff files showed that the required information, references and CRB checks were in place prior to staff commencing work in the home. Staffs receive Skills for Care induction training with different handbooks for each job. Each new member of staff has a mentor who guides them through the induction process. The induction training was evidenced in the files of two new members of staff. A comment in a survey was ‘Sometimes pressure of work and or having insufficient staff means sometimes things are not always acted upon. Due to work I cannot always get to speak to the manager’. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 19 The home has a training plan in place with a senior nursing sister being responsible for ensuring training is up to date and staffs is aware of the available training. Since the previous inspection staff had undertaken training in Moving and Handling, Health and Safety, Fire Safety, Personal Best, Adult Protection and The Mental Capacity Act and NVQ. 70 of staff have achieved NVQ level 2 or above in care and a further 5 were working towards this. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home regularly reviews aspects of its performance through a good programme of self-review, which include seeking the views of residents, staff and relatives. Finance systems are robust. EVIDENCE: The home is run and managed by a qualified and competent person. She manager is a qualified nurse and is currently progressing with the Registered Managers Award. Quality assurance systems were seen to be in place focussing mainly on care documentation, training, activities and medication. There are also monthly audits looking at accidents, pressure sores, maintenance and St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 21 finance. The Area Manager carries out monthly visits and reports on many aspects of the home, the environment, care records, recruitment, health and safety and also has discussion with people who use the service, staff and any relatives in the home. Questionnaires are sent out annually to relatives of people who use the service residents to seek their views about life in the home. An action plan is put in place if any issues are raised. From the previous survey it was suggested to have different flooring in the dining area on the first floor to make it separate from the lounge and this had been done. Staff meetings are held regularly and minutes are kept. A formal supervision system is in place for staff and since the previous inspection supervision was being received more regularly. However the system was not fully up to date and the manager was continuing to monitor and encourage this. A number of health and safety documents and records were examined at the inspection including the accident book, hot water temperatures and various other records. These were all found to be up to date. Discussion took place with the home’s administrator and a check of residents’ finances and records was made. These were found to be correct and showed that any monies kept on behalf of people who use the service is in safe hands. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 22 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 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 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 2 X 3 St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 OP12 OP36 Good Practice Recommendations When people participate in activities this should be recorded in their individual care plan. Care staff should receive formal supervision at least six times a year. St. Marks Nursing Home DS0000000206.V354173.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 © 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 DS0000000206.V354173.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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