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Inspection on 10/11/05 for St. Marks Nursing Home

Also see our care home review for St. Marks Nursing Home for more information

This inspection was carried out on 10th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager has settled into his role and continually seeks the views of relatives, residents and staff to look for ways of developing the service. A relative said she was very happy with the care given to her family member. She said she could always talk to staff about any concerns and was made welcome whenever she visited. The home is well decorated and maintained to a high standard.

What has improved since the last inspection?

Since the previous inspection four bedrooms had been re decorated and new carpets were in place. Carpets had also been replaced in the entrance area, stairs and corridor. The flooring had been replaced in the dining area making it more homely. There were also new chairs and curtains in the lounge area. Lighting had been changed in the bathrooms.

CARE HOMES FOR OLDER PEOPLE St. Marks Nursing Home 1 Hartburn Lane Hartburn Stockton-on-Tees TS18 3QJ Lead Inspector Val Daly Unannounced Inspection 09:30 10 & 18th November 2005 th 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.V263542.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 DS0000000206.V263542.R01.S.doc Version 5.0 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 BUPA (Goldsborough) Limited Mr Brian Sherwin 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.V263542.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age category for individuals with dementia or mental disorder is aged 60 24th May 2005 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. The accommodation is on two floors, accessed by a lift and provides a choice of lounge and dining areas. The spacious ground floor is ideal for entertaining guests and joining in activities whilst the smaller first floor lounge provides a quiet area fro residents to sit and relax or listen to music. Residents can also enjoy sitting in a large enclosed patio garden at the rear of the home during better weather. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection commenced at 10.00 am and lasted for three hours. Residents, a relative, the maintenance man, administrator, a member of care staff and the manager were spoken to during the inspection. Numerous records including maintenance records, staff training, policies and procedures and care plans were examined. Residents were spending their time in the lounges or their own rooms. The communal areas were homely and staff were spending time with the residents, offering assistance or just chatting. A relative said she found the staff open and approachable. What the service does well: What has improved since the last inspection? What they could do better: Care staff to continue to undertake and complete NVQ level 2. Whilst formal supervision for staff has improved not all supervisions were up to date. The assessment documentation for residents was again incomplete. There was no evidence to show that residents or relatives were included in the care planning process. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 6 During discussion with the manager there was an awareness that more input was needed to give more choice to residents regarding religious needs. 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 DS0000000206.V263542.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 DS0000000206.V263542.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): 6 The home does not provide intermediate care. EVIDENCE: At the previous inspection it was identified that the Statement of Purpose contained references to BUPA policies and the document should be more user friendly. This remains outstanding. The home does not provide intermediate care. St. Marks Nursing Home DS0000000206.V263542.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): 8 & 10 Documentation showed that health care needs of residents are being met. Arrangements are in place to help preserve resident’s privacy and dignity. EVIDENCE: At the previous inspection it was highlighted that care planning documentation examined was incomplete. On reading three care plans at this inspection the assessment documentation was again incomplete. There was no evidence to show that residents or relatives were included in the care planning process. A relative interviewed said she had given information to assist with her family member’s care but had not involved herself any further. All residents in the home are registered with a General Practitioner to ensure health care needs are met. Other health professionals, such as Psychiatrists are involved with residents care when needed. Observation of staff practices showed that residents were being treated with respect and any personal care is carried maintaining the persons privacy. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 A selection of activities are available for residents. More choice should be available to meet resident’s religious interests and needs. EVIDENCE: In the three care plans examined there was documentation to show that activities generally took place on an individual basis depending on the capacity of the resident. At the time of the inspection the activities co-ordinator was on long-term sick leave, however the care staff were endeavouring to continue with activities for the residents. A priest visits the home monthly and offers communion to those residents who wish to take part. During discussion with the manager there was an awareness that more input was needed to give more choice to residents regarding religious needs. Staff were observed giving residents choices in daily routines. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These three standards were not assessed at this inspection. EVIDENCE: St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home is clean, warm and well maintained offering residents a homely and safe environment in which to live. EVIDENCE: Maintenance certificates were in place and up to date to ensure a safe environment for the residents and staff. Testing of water temperatures were carried as per BUPA work schedule. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 The deployment of staff on all shifts is appropriate to ensure that residents are supported by an experienced group of staff, however more staff need to complete NVQ training. EVIDENCE: At the previous inspection it was identified that staff files did not contain all the required information. Four staff files were examined at this inspection and they were found to be complete. Staff rotas examined showed that there was sufficient staff on duty to meet the needs of the residents. 35 of care staff had undertaken and completed NVQ 2 training. The manager said that hopefully a further five carers were to commence NVQ training. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 14 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): 33, 35 & 38 Views are sought via a quality assurance programme in order to continue to develop the service. Financial procedures are robust. Arrangements to ensure that the health and safety and welfare of residents and staff are in place. EVIDENCE: BUPA conduct an annual quality assurance programme and relatives and staff are asked for their views on the service. The questionnaires are sent out directly from Head Office to ensure a fair assessment. The organisation has robust financial policies and procedures. Examination of financial records showed that procedures were being followed. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 15 Staff training records showed that staff had received training in Health and Safety. Also staff in the home was in the process of completing a workbook for health and safety, which would be taking approximately two months. St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 St. Marks Nursing Home DS0000000206.V263542.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP31 Regulation 17 9 Requirement Care planning documentation must be complete. The application for the manager is required to be completed. Timescale for action 30/12/05 30/12/05 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. 3. 4. 5. OP36 Refer to Standard OP1 OP7 Good Practice Recommendations The Statement of Purpose should be more user friendly, references to BUPA policies being removed The manager must ensure the plan of care is signed by the resident and/or their representative to show their agreement with the care plan. More choice should be available to meet resident’s religious interests and needs More care staff need to complete NVQ training. Care staff should receive formal supervision at least six times a year. DS0000000206.V263542.R01.S.doc Version 5.0 Page 18 St. Marks Nursing Home Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 DS0000000206.V263542.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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