Inspection on 07/12/06 for St. Marks Nursing Home

This inspection was carried out on 7th December 2006.

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.

Other inspections for this house

St. Marks Nursing Home 10/03/08

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 Jackie Herring Key Unannounced Inspection 7th December 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St. Marks Nursing Home DS0000000206.V321915.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.V321915.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 Mr Dan Richard Joseph Yates 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.V321915.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 10th November 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 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 £353:00 to £587:00. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed with the involvement of two inspectors across three inspection days, twenty-four inspection hours in total. 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. Residents and relatives were spoken to during the inspection to seek their views, as were staff members and the home manager. A number of records were looked at including resident’s assessments and plans of care, staff recruitment records, complaints and maintenance records along with the pre inspection questionnaire. Indirect observations also took place, as due to health needs, a large number of residents were not able to be involved in informed discussion about their care at St Marks Nursing Home. A meeting also took place with the responsible individual following the second day of the inspection and we also met again towards the end of the inspection. A number of concerns were raised with the responsible individual all of which were acknowledged and steps were taken to address the most immediate matters raised. It was clear from the discussions that took place that there is a commitment to address the issues raised and that some of the concerns had been identified through a recent in-house audit of some of the systems. It was agreed that areas for improvement would be completed within short timescale, as such, it was agreed that an early key inspection would take place in the next inspection cycle. What the service does well: St Marks provides a comfortable home for residents to live, which is clean and well maintained. Relatives said that residents were very happy living at St Marks and believed they were well cared for and supported by the staff team. One relative said, “I am quite happy that she is well cared for, they have done quite a lot for her”. Residents said, “The staff are courteous, treat you with dignity and on the whole very well, they are very helpful”. A relative whose loved one had been in previous care homes said, “It’s smashing here, consistently good standards, I am glad he/she is here and I would recommend it, better here than anywhere else”. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A number of areas have been identified as in need of improvement. The Responsible Individual had also identified a number of areas in need of improvement and was in the process of addressing the matter. Of the records examined, there was much work to do to ensure that detailed information about individual residents needs along with supporting care plans were in place. This relates to pre admission assessments, ongoing needs assessment and an appropriate range of care plans to ensure that social, personal and healthcare needs are met. It is however acknowledged that work is underway to make the required improvements. Activities require further thought to ensure stimulation is provided to residents. The medication systems are in need of some review in regard to record keeping and one practice issue. The review of the new meal arrangements should continue and needs to ensure that residents are given a choice and are provided with good, nutritional meals. The complaint and protection of vulnerable adults procedures and supporting records are in need of review and need to be recorded properly. Although there are effective systems in place to manage the recruitment, the actual practise was found to be in need of further improvement, this particularly related to the actual record keeping of staff files, all of which did not contain all of the required information. The mandatory staff training needs to be completed at regular intervals by all staff at the home as does staff supervision. The skill mix particularly in relation to qualification and experience of staff is also in need of review The home is generally well maintained, however the redecoration and refurbishment programme should continue. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 7 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.V321915.R01.S.doc Version 5.2 Page 8 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.V321915.R01.S.doc Version 5.2 Page 9 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): 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed prior to admission to the home although not in sufficient detail to demonstrate their needs can be fully met. EVIDENCE: Selected samples of resident’s files were looked at during the inspection. The qualified staff said that it was usual for key individuals within the home to conduct a pre admission assessment, copies of which were available within the files. These did not all have full details about individual health and care needs and associated risk factors. For example one did not initially indicate that legal mental health status and another did not detail potential behavioural risks. It was not fully demonstrated if the home was able to meet health and care needs of all of the residents admitted. One recent admission was in the process of being discharged to another care home, as their needs could not sufficiently be met. Also in the files looked at, there was no copy of the care management assessment, although again staff said that these would usually be obtained. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 10 Of the files looked at, all of the residents were being funded by the local Commissioning Authorities and documentation stated that their terms and conditions applied. There was also information about change in fees when residents’ needs had changed and through the reassessment process. Privately funded residents are provided with a contract, which included details of fees and room number. St Marks does not provide Intermediate Care. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although residents and relatives are happy with the care provided, the resident’s records, including assessments and care plans did not fully details health and care needs and do not demonstrate the resident’s needs are being met. Residents are treated with dignity and respect. The medication procedures are in need of review and updating to ensure robustness. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 12 EVIDENCE: A selected sample of four residents files were looked at during the inspection. Whilst the actual documentation format is good, with clear information flow and relevant assessment tools the file looked at did not contain sufficient information or detail to show how social, health and medical needs are met. There were clear deficits in all of the care records examined, examples of this includes; one resident who had been receiving ongoing respite care had not had their care needs assessment since first point of admission, which was some considerable time ago. Another resident’s records raised some cause for concern in regard to their medical needs, for which immediate action was requested to address this. In other files examined, there was lack of information in regard to potential risks and the impact this could have on other residents and there was the need to have improved and more detail information within care plans. Some concerns were also raised about the increased involvement and support of Community Psychiatric Nurses. Records did show that there were visits from GP’s, CPN’s, District Nurses and Opticians and Chiropodists. The care manager said that all of the care records were in the process of being audited with a view to improving the level of detail and content. This was also confirmed by the responsible individual, who said that during a recent audit a number of deficits had been identified and that staff were in the process of reviewing the care records. It was confirmed through discussion that work was underway to ensure that these records were improved. The medication systems were looked at and it was noted that there was the need for some improvements. On the third inspection day and whilst the medication systems were being looked at, a qualified nurse “potted up” three residents medication. Immediate steps were taken to prevent any mix up and potential harm to residents. The manager said that there had been some problems with the dispensing pharmacy and they were in the process of changing to a different pharmacy. During an examination of the records, it was identified that the systems for checking in ordered medication was not appropriate as the staff were checking against the previous medication administration sheet rather that the prescription or record of what had been ordered. It was also identified that where medication is handwritten on the Medication Administration records, these were not always being signed and countersigned and the amounts not always recorded, making any audit difficult. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 13 There were gaps in the recording of the medication fridge temperature, with thirteen gaps in December and on the third inspection day, the thermometer was not working. All of the medication was being appropriately stored and the system for returning or disposing of unused medication was good. An audit of controlled drugs took place and all was in order as were the records, however there was no recent evidence that the controlled drugs were being audited. Accident records were looked at and the required accident analysis had not been completed for some time and a number of residents were identified as being at risk of falls. Due to there being no analysis, it was not clear what steps had been taken to reduce the risk of falls, as a small number of resident had been having falls for some months. Relatives said that residents were very happy living at St Marks and believed they were well cared for and supported by the staff team. One relative said, “I am quite happy that she is well cared for, they have done quite a lot for her”. A resident said, “The staff are courteous, treat you with dignity and on the whole very well, they are very helpful”. A relative whose loved one had been in previous care homes said, “It’s smashing here, consistently good standards, I am glad he/she is here and I would recommend it, better here than anywhere else”. Although there is a named nurse and keyworker system in place, it was unclear how this information was shared with residents and/or their relatives. During discussion with a couple of relatives, they did not know about this. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities provided by the home are limited and do not provide residents with stimulation. Meal provision within the home has recently been reviewed with a view to improving meals and resident nutritional needs. Residents are able to maintain contact with family and friends. EVIDENCE: During discussion with a number of staff they said that there were insufficient activities for residents to be involved in. There had in the past been a dedicated activities co-ordinator, however this post is now vacant and had been for three months. This role is covered by another staff member when it is convenient. An activities file was looked at, however this was not up to date. One staff member said, “There is less than a handful of activities, some residents play dominoes or snakes and ladder, but there is nothing much for other residents, just the occasional entertainer”. Relatives said they could visit when they wanted and that they were kept informed of changes to their loved ones. One relative said they were always welcomed into the home and were always offered refreshments. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 15 Staff were spoken to about what daily life was like for residents. One staff member spoke of a fairly relaxed and flexible home, they acknowledged that there were difficulties at times with choice and decision making due to dementia, however said, “you have to ask them, show them and judge their reaction and make a decision from there”. Time was spent with residents and it was not possible to discuss in detail what life was like for them at St Marks. Through observation, residents wore jewellery such as a watch and earrings, they were nicely and appropriately dressed and those residents who were chatted to were observed to be smiling and one said, “I am alright here”, while another said, “It is OK here, I can go out with my daughter”. There were mixed views about the meal provision. Some staff thought it was good, others thought it was adequate whilst some staff didn’t think it was that good. Menu’s had recently been reviewed and the home were in the process of introducing new systems for ensuring that meals provided good nutritional benefits to the residents. Menus were looked at, which was a four-week rolling menu. It offered choice and alternatives. One lunchtime meal was observed and on this occasion, the food was not well presented, there was no choice. One resident said, “I’m not sure about choice, there is no real choice, they give you what they have and there are too many sandwiches”. The cook said, “If they don’t eat what is put out then they are offered and alternative”. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is good, however the records of complaints and associated investigation need more detail. The systems for protection of vulnerable adults are in place however more staff training is required to ensure that residents are adequately protected. EVIDENCE: Systems are in place for managing complaints and the complaints procedure is on display within the main entrance of the home and contained most of the information needed. There is the need to add in commissioning authorities details. Complaint records were looked at during the inspection and found to be incomplete, with not all concerns or complaints raised having been recorded. It was unclear how thoroughly any complaints had been investigated, as the records did not contain this level of detail. The pre inspection questionnaire detailed that relevant policies and procedures are in place in respect of Protection of vulnerable adults. Although training had taken place in regard to protection of vulnerable adults, it was unclear how many staff had been trained and the action they would take in the event an incident occurs or allegation is made. There was one example of potential abuse that had not been reported or investigated accordingly; immediate action was taken to address this. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a suitable environment to suit their needs and lifestyles, which is clean, well maintained and reasonably decorated. EVIDENCE: A tour of St Marks took place and was observed to be clean and odour free. Housekeeping staff were observed going about their daily cleaning duties. Handrails were in place on corridor walls and there was a range of equipment such as hoists to meet resident’s needs. Residents live in a warm and reasonably comfortable home, which is clean and well maintained. There is space for residents to move around the home freely. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 18 A programme of redecoration and refurbishment is underway and a number of areas had been improved. This included a number of bedrooms, which had been tastefully redecorated. The storage of a seated weighing scale, at the top of one of the stairwells was seen as a potential accident risk to staff and the manager confirmed that this would be moved. Two residents at times share one of the double rooms; there were no privacy screens in place for the times when this room is shared. A small number of areas were identified as in need of attention, this included, one of the bath panels, which was falling off, paintwork in one of the bathrooms, some bathroom, and toilet doors were worn in appearance. One resident was really proud of their bedroom and took real pride in showing it to the inspector. It was nicely decorated with much evidence of personalisation, including flowers, TV and music centre. Another resident said, “I think it is a beautiful place”. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The actual skill mix and qualification of staff is not always as required. There was lack of evidence of sufficient recruitment checks being undertaken to ensure the protection of residents. It was unclear if the staff had the training to ensure the residents needs can be met. EVIDENCE: A number of staff files were looked at and on the first day of inspection they were found to be not well maintained and not very orderly and all of the required information was not available, such as evidence of Criminal Bureau Checks and Qualified Nurses checks. The majority of this information was available on the second day of inspection. It was however, identified that the recruitment records and systems were not as robust as required, with a small number of staff having commenced employment without all of the required checks such as suitable references. The staff duty rota was examined and there was discussion with staff about skill mix and staffing levels as the home was rarely being staffed with the appropriate qualification of nurse, that being a Registered Mental Nurse. Concern had also been raised about this via North Tees Primary Care Trust. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 20 Some concerns were expressed about staffing levels particularly in respect of the first floor unit. Staff said that due to the complexity of residents needs and behavioural needs that there were times when they only adequately met the residents needs. Staff training records were poorly maintained, with loose sheets of paper and not filed properly. Workbooks, such as Health and Safety were evidenced in files and dated for example 12/05; however there was no signature to show that this training had been completed. The mandatory training programme was looked at, this again did not contain sufficient information and all of the information did not match that on the individual employees personal training records. Several personal training records were looked at and some had no entries since Jan/Feb 2005. The statutory/mandatory training matrix from BUPA was available to see and the outline plan was good, however this was blank on day one of the inspection and by day three of the inspection had been completed ready for use. Records did not support that all staff have been appropriately inducted. Some staff said they thought they had completed a small induction booklet. Another member of staff said they had worked alongside other carers but had not had any real induction. The pre inspection questionnaire detailed that 33 of staff had achieved NVQ Level 2 in care; by the time of the inspection this had increased to 60 , which is good. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents and relative are very satisfied with the home and care provided, a number of systems need to be developed further to enhance the running of the home and to ensure ongoing health, safety and welfare of residents. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 22 EVIDENCE: There is a registered manager in post who has the required experience and qualification. Some of the systems to ensure effective management had not been fully completed and updated. Staff said that morale was a little low at the moment, one staff member said, “Staff morale needs lifting”, another said, “Things seem to have deteriorated over the past 6-12 months, particularly over the past few months”. The Responsible Individual had commenced some work within St Marks and an action plan detailing similar findings to the inspection was made available and included action to be taken and target dates. Work in regard to the action plan is ongoing. The systems for managing resident’s personal allowances are an agreed BUPA procedure and had records in place to support a sound system. Staff records could not demonstrate that all staff were receiving supervision on a regular ongoing basis. Some staff during discussion said that they had received supervision. Systems and records to support health and safety such as weekly fire checks and checking of water temperatures need to be improved. There were some gaps in the weekly fire checks and on occasions, the hot water checks show that the water is too cold. In terms of quality assurance, monthly regulation 26 visits take place by the responsible individual, which are reported on and an action developed as a result. During discussion with the manager it was confirmed that a range of quality initiative are in place and that BUPA as a company also conducts an annual survey, which an independent company analyses. There is a suggestion box in reception and regular staff meetings take place. A regular St Marks Newsletter is also produced and the manager said they are going to be working with some relatives to develop “Friends of St Marks”. St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 23 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 1 X 2 St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 24 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 OP3 OP7 Regulation 14 14 Requirement Timescale for action 28/02/07 Residents’ assessments must be developed further and include a detailed assessment of needs. Care planning documentation 30/03/07 must be complete. The individual residents documentation must be reviewed and must contained detailed up to date assessments and where area of needs have been identified, specific plans of care, which must be reviewed and evaluation. The work that has already commenced to make the required improvements in this area must be completed. Where healthcare risks have 28/02/07 been identified there must be specific risk assessments in place along with supporting records. Accident analysis must be completed and plans of care must be in place for the management of accidents. The administration of medication must be reviewed and must be a DS0000000206.V321915.R01.S.doc 3. OP8 13 4. OP9 13 28/02/07 St. Marks Nursing Home Version 5.2 Page 25 5. OP12 16 6. OP16 22 7. OP18 13 8. OP27 18 9. OP29 19 10. OP30 18 11. 12. OP32 12, 13 13 OP38 safe procedure in accordance with NMC and The Royal Pharmaceutical Guidance. Immediate action was taken to address one of the areas identified. There must be a plan of varied/suitable activities and outings for residents residing at the home, which is also linked to lifestyle preferences. The complaints procedure and complaints records must contain up to date information and must detail all complaints made and evidence of any associated investigation. Further training in respect of protection of vulnerable adults must be implemented and the procedure must be updated. Any allegation must be recorded and the appropriate action taken. The appropriate qualification and skill mix of staff must be on duty and available to meet the category of care provided at St Marks. The staff files must contain the information as specified in Schedule 2 and procedures must be robust ensuring protection to residents. All staff must complete a formal induction within the required timescales and this must be evidenced on their files. The current action plan regarding effective management systems must be completed. All staff must receive regular mandatory training and records must be in place to support this. 30/03/07 28/02/07 30/03/07 30/03/07 28/02/07 30/03/07 28/02/07 30/03/07 St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose should be more user friendly, references to BUPA policies being removed. (This was not looked at on this occasions, remains in place from previous inspection) The new menu system and meal provision to resident should continue to be monitored. Staffing levels should continuously be reviewed to ensure that there are sufficient numbers to meet the needs of the residents. Care staff should receive formal supervision at least six times a year. Records in respect of water temperatures and weekly fire checks should be completed at the required intervals. 2. 3. 4. 5. OP15 OP27 OP36 OP38 St. Marks Nursing Home DS0000000206.V321915.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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.V321915.R01.S.doc Version 5.2 Page 28 - 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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