Inspection on 30/06/05 for St Marks Nursing Home

This inspection was carried out on 30th June 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.

Other inspections for this house

St Marks Nursing Home 07/02/07

St Marks Nursing Home 01/12/05

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 Announced 30 June 2005 9:00am 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 CS0000018197.V184793.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Marks Nursing Home Address 145 Hylton Road Millfield Sunderland SR4 7YQ 0191 567 4321 0191 565 5834 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) Dr Lim Wyn Mrs Pauline Jane Laverick Care home with nursing 35 Category(ies) of PD Physical disability (4) registration, with number OP Old age (35) of places St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3/3/05 Brief Description of the Service: St Mark’s 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. It has two floors that can be accessed by a passenger lift and stairs. 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. 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. The home is also within relatively easy reach of the seacoast. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced, and was carried out by one Inspector over one day. Before the inspection a questionnaire had been completed by the Manager, which gave up to date information about the Home to allow more time to be spent with residents on the day. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out. The Inspector spoke with fifteen residents, four visiting relatives, and seven staff including the cook, and the Manager. The Inspector also had lunch with some residents in one of the two dining rooms. A number of records and documents were examined including residents’ care plans. An action plan had been received from the Provider following the last inspection and all but one of the requirements and recommendations from that inspection have been completed. A number of CSCI comments cards were received before the inspection and all were generally very complimentary about the Home and the staff. What the service does well: The Home is well managed with constant support from the manager and deputy and residents spoke of the staff giving a good standard of care. The Home had a very welcoming and friendly atmosphere, which residents and visiting relatives informed the Inspector, was always the case. All visitors to the home were made welcome and treated with courtesy and respect by the staff. A number of staff employed have worked at the home for a considerable time and provide consistency and continuity of care to the residents. Residents and visiting relatives spoke well of the staff. Some made such comments as “I’m very happy with the home, no complaints”, “I’ve only got to press the buzzer for assistance and they’re there”, I have everything I need here, lots of my own things”. Meals are varied and choices and alternatives are available. The residents enjoy ‘home style’ cooked foods and they were very complimentary about the quality of foods served. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 6 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 CS0000018197.V184793.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 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 standard(s) 3 & 4 Appropriate assessments of service users needs are carried out prior to and following admission, and subsequent assessments ensure that residents’ needs are met. EVIDENCE: Examination of resident’s records and discussion with the Manager and Deputy Manager indicated that prior to admission to the Home prospective residents had an assessment carried out by the Care Managers and a pre-admission assessment by the Home staff. Following admission a further assessment is carried out. A number of residents in the Home stated that their needs were being met to their satisfaction and activities that could be observed throughout the day indicated that they were. One resident and also a relative stated that she had lived in another home, but this one catered for her needs and wishes far better. St Marks Nursing Home CS0000018197.V184793.R01.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) 7,8 & 10 Service users appeared well and spoke of staff meeting their health and personal needs. Service user’s care plans are in place but still do not fully reflect and document their observed needs. This can limit the guidance available regarding care practice and consistency. Staff at the home support service users with their social, health and personal care needs in a way that treats them with respect and generally promotes their rights and dignity. EVIDENCE: In conversation with the Manager, Deputy and other staff, they displayed a good knowledge of individual residents and their needs. They were able to say how those needs would be met and how identified risks were managed. A sample of care plans were examined and contained good basic information but more and specific detail, about the care delivered, and addressing changing needs should be recorded. Health related risk assessments were carried out and care plans as to how they were to be acted upon with reference to falls, nutrition and pressure damage assessment were available, but the information in these needed to be expanded upon. The care plans contain information and St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 10 records of the input by GP’s and other relevant professionals. Residents who were spoken with described how their health care needs were met. One resident said, “they tend to my health care very well”, and a relative who visits daily said “ my husbands health is much better since he came here, I have no worries”. Since the last inspection there has been an improvement in care planning documentation, however further development must be undertaken. Residents described how staff maintained their privacy and dignity and that they always knocked on their doors and waited for a reply before entering. Residents also confirmed that they were treated respectfully and in a kind manner by all members of staff, especially when personal care was being carried out, such as bathing. Staff were observed to treat residents during the mealtime, in a sensitive and respectful manner, especially those who needed assistance to eat. Notices were displayed in a number of residents bedrooms regarding their individuals’ ‘moving and handling’ risks, and were in prominent places. This practice could potentially compromise issues of privacy and dignity for those residents when visitors or relatives are there and it was suggested that they be placed in more discreet places if they need to be in individuals’ rooms. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 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 standard(s) 12 & 15 Residents are offered the opportunity of participating in a wide range of leisure and social activities. Links with family, friends and the community are encouraged, supported and maintained. Residents are offered and receive varied, wholesome, nutritious and wellpresented meals. EVIDENCE: Conversations with the Manager and staff, and a number of residents, and reference to the programme displayed, confirmed the range of various activities, events and outings available. A notice board of photographs of residents and staff, taken at various outings, is displayed to highlight the events. One relative spoke of the “good level of activities and opportunities to go out” and two residents spoke of their visits to the local church hall and the shops. The Inspector joined residents and one relative in one of the lounge/dining rooms, for lunch. The tables were very pleasantly set with condiments, serviettes, sugar and milk, and were pleasantly decorated. Cold drinks were offered during the meal and the meal was tasty and well presented. A white board in the dining room indicated in a clear and legible way, what the meals of the day were. Alternative choices were served to those people who St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 12 requested them. Residents confirmed that such facilities and choices were offered on a daily basis and that they always enjoyed their meals. Staff were attentive and offered assistance to those who needed it, in a discreet, courteous and unhurried manner. The environment and the atmosphere were sociable and pleasant with very good interactions taking place between residents, staff and visitors. Inspection of the kitchen confirmed a clean, well-organised environment with good stocks of foods including fresh fruit and vegetables and small tinned and packet foods to allow individual choices and requests to be given. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 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 standard(s) 18 Appropriate Adult Protection procedures have been implemented in the home to guide staff in the protection of the service users from abuse. EVIDENCE: There is a Protection of Vulnerable Adults (POVA) procedure in the Home and a Whistle blowing policy, which has been reviewed and updated within the past six months. The Local Authority Multi Agency Procedure for the Protection of Vulnerable Adults (MAPPVA) is also available in the Home for staff guidance. Staff have received training on the protection of Vulnerable adults. Staff were able to describe and give a good account of appropriate actions to be taken on suspicion of, or witnessing abuse. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 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 standard(s) 19,22,25 & 26 The home was well maintained and decorated, with continued re-decorating of communal areas taking place, offering a homely, pleasant and safe environment for residents. Equipment and facilities are provided to enable residents to remain independent. Residents live in warm, well-lit and comfortable surroundings that are clean and odour free. EVIDENCE: Evidence was seen of the continued planned re-decoration and refurbishment of the home. The main ground floor lounge/dining room has been redecorated since the last inspection and provided with very attractive new curtains and accessories. The residents who spoke with the Inspector stated that the room was lovely and they liked the colour scheme and the new curtains. The first floor smoking lounge was scheduled to be re-decorated within the next week and the previously recommended ventilation system was St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 15 to be provided. Residents confirmed their awareness of the plans and a notice was also displayed for information, to confirm this. Information received from the Manager following the inspection indicated that this work had been carried out to the residents’ satisfaction. The home was clean to an exceptionally good standard and was odour free. However, in conversation with the housekeeper it was evident that no domestic staff cover is available after 2pm. Domestic tasks such as vacuuming the lounge/dining room after tea are carried out by the care staff as are any other domestic tasks that become necessary, such as cleaning toilets and bathrooms. Discussion took place with the Manager regarding this and the suggestion that the domestic staff shifts should be staggered in order to provide some cover in the early evening. The Manager agreed to look into the matter. The heating and lighting in the home was satisfactory and water temperatures are monitored and recorded with good records maintained. Samples of water temperatures tested by the Inspector were at acceptable levels. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 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 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) The outcomes in this section were not assessed on this occasion as the Pre-inspection questionnaire indicated that staffing numbers, skill mix and training were appropriate. EVIDENCE: St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 17 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) 32, 36 & 38 The Manager offers clear leadership and direction to staff, which the Deputy supports, so that they can consistently meet the needs of service users. Staff are appropriately supervised which assists in promoting and safeguarding the best interests of the residents, by a well managed staff team. The health, safety and welfare of residents are promoted and protected through staff training and good practices. Equal attention is needed for all staff in the home in high risk areas such as the kitchen. EVIDENCE: All staff who were spoken with confirmed that the Manager was approachable, supportive and fair. She enabled them to attend a good range of training and supports their contributions to the running of the home. A student nurse on placement to the home was spoken with and confirmed the good level of support she was receiving from her mentor, who was the Deputy manager and St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 18 of the way in which staff practice and uphold the recognised values, principles and entitlements of life, for the residents. All staff who were asked confirmed that they received two monthly supervision and spoke of the value it offers them in their work. A programme of planned supervision seen in the Manager’s office, and a sample individual staff files that were seen, confirmed this practice took place. Health and safety practices in the home were generally satisfactory, however, the cook advised the Inspector when asked, that in kitchen the ventilation canopy over the large ovens and hobs was cleaned by the kitchen staff, although not effectively due to the height and size of the canopy. This clearly presents a health and safety hazard and risk because of the need to stretch and climb to reach. In discussion with the Manager she agreed to pursue the issue of obtaining a specific contracted service to carry out the work. St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 19 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 x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x x 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 3 x x x 3 x 2 St Marks Nursing Home CS0000018197.V184793.R01.doc Version 1.30 Page 20 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. Standard 7 Regulation 15(2) Requirement The Manager must pursue the development of the care plans in order to improve the documentaion process. (Timescale of1/7/05 not met) Timescale for action 30/9/05 2. 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 38 27 Good Practice Recommendations The Manager should pursue the provision of a specific service to clean the kitchen canopy, to prevent accidents to staff. The Manager should pursue review of the domestic staff shit patterns. 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