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Inspection on 24/05/05 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 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 home has a team of staff who have worked there for many years which ensures continuity of care for the residents. The activities co-ordinator continues to try to find activities for the residents to enjoy and include other members of staff. The environment is well maintained and re decoration is ongoing.

What has improved since the last inspection?

There are dining facilities on both floors for the residents, which gives more choice and allows for the supervision of smaller groups of people.

What the care home could do better:

The complaints procedure and other information within the Statement of Purpose could be made clearer by removing the references to BUPA policies. Relatives should be made aware of care planning and be encouraged to be involved. Medication administration records must be fully completed. Staff personnel files must include all the required information. A training plan for staff must be in place and formal supervision sessions should be up to date.

CARE HOMES FOR OLDER PEOPLE St Marks Nursing Home 1 Hartburn Lane Hartburn Stockton-on-Tees TS18 3QJ Lead Inspector Val Daly Unannounced 24 May 2005 09:30 am 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 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 B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Marks Nursing Home Address 1 Hartburn Lane Hartburn Stockton-on-Tees TS18 3QJ 01642 670777 01642 671365 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA (Goldsborough) Limited Care Home with Nursing 39 Category(ies) of DE(E) - Dementia over 65 registration, with number MD - Mental Disorder of places DE - Dementia St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Age category for individuals with dementia or mental disorder is aged 60 Date of last inspection 24 November 2004 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 proviode 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 louinge and dining ares. 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 B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 9.30am and lasted for four hours. Residents, two relatives, the manager and a member of staff were spoken to during the inspection. Numerous records including care plans, medication records, menus, and staff records were examined. A tour of the premises was carried out. Residents appeared comfortable, were well dressed and staff were seen to be interacting with them. Two relatives had some concerns regarding some aspects of care and the manager was looking at the concerns raised. What the service does well: 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. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 7 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 standard(s) 1 & 3 The Statement of Purpose contains the required information, however reference to BUPA policy numbers should be removed to make the document more user friendly. Resident’s needs are assessed prior to them moving into the home. EVIDENCE: There is a ‘Welcome Pack’ for a resident moving into the home, which includes information about menus and catering times, GP’s, Dentist, Optician, chiropody, local churches and activities. The home has a Statement of Purpose, which includes a summary of staff employed in the home with descriptions of their uniforms. The complaints procedure within this document is not clear and refers to BUPA policies, which are not relevant to residents or their families. There are further references to BUPA policies throughout the Statement of Purpose. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 8 Three resident’s files were examined and they each contained an assessment, which had been carried out prior to the person moving into the home. The manager also carries out his own assessment, meeting with the prospective resident, either in their own home or in hospital. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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 standard(s) 7 & 9 Care plans were incomplete and did not reflect the needs of the residents. Medication records were not fully completed. EVIDENCE: Three resident’s files were examined and none of the care planning documentation was complete. There was no evidence to show that relatives or residents were included in the care planning. Two relatives interviewed were unaware of their family member’s care plan and had not been asked to be included in the drawing up of it. The relatives also had concerns regarding aspects of the care their family member received. The manager had been made aware of the concerns and was in the process of carrying out an investigation. Assessments were incomplete. Care plans were not evaluated. Bassol behavioural scale is used, however care plans were not in place where they had been indicated as needed in the Bassol scoring. Risk assessments required more detail. Medication records examined showed gaps in recording in that the reason for medication being omitted was not given. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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 standard(s) 13 & 15 Visitors are made welcome to visit at any time. New menus show improvement in choices of meals. EVIDENCE: During the inspection it was noted that visitors were free to visit at any time. The visitor’s register showed that there were people visiting the home throughout the daytime and evening. Menus were examined, and at the time of the inspection new four weekly menus were being introduced. Two relatives interviewed were pleased at the changes to be made with the meals. They said they visited every day and felt that whilst four weekly menus had been in place previously the food had been repetitive as if it was from the same week. They also felt that some of the meals, were not always suitable for elderly people as in chicken nuggets and beefburgers. There had been a large notice board in the lounge/dining room, which showed the meals for the day. However this had been taken down, the new manager said he was going to replace it. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 The home has a robust complaints system in place. Staff have received training in adult protection issues which helps protect the residents. EVIDENCE: The complaints records showed that residents and relatives are listened to and details of matters of concern are included in them. The manager responds in writing to the complainant. Staff have received training in adult protection which was evidenced in personnel files. Information is available in the home for residents and relatives. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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 standard(s) 24 & 26 Resident’s bedrooms contain personal items. The home was pleasant and clean. EVIDENCE: On touring the home it was noted that resident’s bedrooms contained personal possessions. Two relatives interviewed said they had brought personal photographs and ornaments for their family member. The home was clean and odour free. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 Policies/procedures for the recruitment of staff must be followed. Training for staff must be planned and consistent. EVIDENCE: When staff are employed there is a clear policy in place to follow. It includes all measures to ensure residents’ are protected and Criminal Bureau Checks and references are sought. However four staff files were examined, two of them only contained one reference. Staff training records were examined which showed training is inconsistent and fire training has not been undertaken since July 2004. It is good practice to ensure all staff employed have fire training twice a year. A training plan should be in place with dates included for the year. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 36 The application for the manager is required to be completed. Staff require formal supervision. EVIDENCE: The registered manager has left the home and the acting manager is in the process of applying to the Commission for Social Care for registration. Staff supervision records were not up to date. Care staff should receive formal supervision at least six times a year. Supervision records had not been updated since November 2004. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION x x x x x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x 2 x x St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 16 Yes 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. 2. 3. 4. Standard OP7 OP9 OP15 OP29 Regulation 17 13 16 19 Requirement Care planning documentation must be complete. The reason for medication being omitted must be recorded. Menus must show that suitable, wholesome and nutritious food is provided. Staff files must include the information required in Schedule 2 of the Care Standards Act 2000 A training plan for staff must be in place. Staff must receive training in Fire Safety. The application for the manager is required to be completed. Timescale for action 30th July 2005 30th July 2005 30th July 2005 30th July 2005 30th JUly 2005 30th July 2005 5. 6. OP30 OP31 18 9 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 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. B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 17 St Marks Nursing Home 3. OP36 Care staff should receive formal supervsion at least six times a year. St Marks Nursing Home B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit B, 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 B51-B01 S206 St Marks V227545 240505 Stage 4.doc Version 1.30 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. 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. 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