Inspection on 07/02/07 for St Marks Nursing Home

This inspection was carried out on 7th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Marks Nursing Home 01/12/05

St Marks Nursing Home 30/06/05

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 Mr Tom Moody Key Unannounced Inspection 7th February 2007 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 DS0000018197.V329225.R02.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 DS0000018197.V329225.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marks Nursing Home Address 145 Hylton Road Millfield Sunderland SR4 7YQ 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) 0191 567 4321 0191 565 5834 Dr Lim Wyn Mrs. Pauline Jane Laverick Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (4) of places St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: St Marks 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. 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. En-suite facilities are not provided but there are adequate and accessible bathrooms and toilets situated around the Home. There are two floors that can be accessed by a passenger lift and stairs. The corridors and door widths allows easy access in and around the Home for wheelchair users. 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. It is also within relatively easy reach of the seacoast. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out by one Inspector over one day on 7th February. The inspector spoke to a number of service users the Manager, a number of nursing and care staff, and the Domestic supervisor. Visiting relatives were also spoken to. A sample of records were inspected for service users who were case tracked. These included, care plans, complaints records and medication and records of personal allowances. Staff files were also seen including training and recruitment documentation.. The building was checked to see the facilities and equipment available for residents, and the general maintenance and safety of the property. What the service does well: The Home has a very welcoming and friendly atmosphere. All visitors to the home were made to feel welcome and can visit at any time. The staff, manager and deputy manager are approachable and communicate well with service users and their relatives. Care practice shows sensitivity and staff carry out care tasks with attention focussed on individual service users. The Home offers a homely and pleasant environment for residents to live in. The home looks after the healthcare needs of the service users and has a good relationship with visiting professionals. The home provides a good variety of social and entertainment opportunities for service users, and has good links to the surrounding community. Quality surveys are carried out as well as analysis of incidents and accidents. Practice is changed in line with these finding to ensure the care environment is improved for service users. The home is well managed by a committed team and the proprietor visits frequently. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users entering the home have some of their needs accurately assessed by social care and health service staff. The home makes it’s own assessment in addition to this. Most service users and their family have the opportunity to visit the home before they come to stay, unless there are exceptional circumstances and accurate information is available about the home. This allows them to make an informed choice about their stay. EVIDENCE: The home has a satisfactory service user’s guide that provides a good level of information to service users in an easily understood format. It contains the necessary information about the staff and manager of the home. The manager stated that service users can visit the home and all potential service users are provided with a service users guide. The manager also stated that service users have contracts and they were usually local authority based. Examples were seen in service users records. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 9 Service users visitors confirmed they had been given “good” information about the home before their relative went there and they were happy with the way staff communicated with them. The manger confirmed that the placing authority did their own assessment and that the home did their own assessment of needs independent to this. Records contained both assessments and this provided a comprehensive picture of service users needs, including social, spiritual and aspirational needs St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is exellent. This judgment has been made from evidence gathered both during and before the visit to this service. Care plans had good information in relation to healthcare needs and the care that was observed was good. The homes medication systems are being adhered to and service users are protected by as safe system of medication that is properly operated by staff. This demonstrates that the home is meeting all of service user’s healthcare needs. EVIDENCE: The providers self-assessment indicates that there have been few reported incidents or complaints since the last inspection. There have only been 9 deaths within the last year and accident rates are unremarkable. There is one service user with pressure damage. Care plans for some service users were examined. They were well written and contained all the information necessary to ensure service user’s needs are met. This includes nutritional assessments, information on pressure damage risk and moving and handling. The care plans indicate the involvement of clinical specialists. There were good risk assessments documented and evidence that this was carried out in practice. Many beds showed evidence of alternative strategies to bed rails, such as foam-wedges and variable height beds. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 11 The home has appropriate policies, and practice to ensure service users receive their medication in a safe way. Observation of the administration and storage indicated this was good and in line with policies. The Medicine Administrations Records that were seen by the inspector were accurate and well kept. The Manager states relationships with the local GP practice is good and the local health centre at Millfield has good facilities. The home has a policy on resuscitation, based on the local health care trust model, and this was also evident in care plans. This model involves service users and relative to be involved in decision making about resuscitation at the end of life and should eliminate unnecessary and undignified attempts at resuscitation when this is no longer appropriate. Staff were seen to talk respectfully to service users and listened attentively to what they said. Staff knocked before entering service users rooms and gave support in a way that was unhurried and focussed on the individual they were dealing with. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is exellent. This judgment has been made from evidence gathered both during and before the visit to this service. The service users can make full use of all of the homes facilities and show signs of having their own interests and possessions. There is evidence of visitors involvement in service users care and recreation. Service users enjoy an appetizing selection of meals in pleasant surroundings. All of this indicates most service users needs and preferences are being met by the home and that they have choice and control over many areas of their lives. EVIDENCE: There have been few reported incidents or complaints about this area of service. The provider’s self-assessment indicates a varied social programme is available for service users. The manager said she has appointed a new activities co-ordinator. The manager shows a good awareness that social activity should not always focus on the most responsive service users and she insists that the co-ordinator spends some time with service users who have communication difficulties. The co-ordinator keeps records to show the type and duration of activities for each service user. Service users confirmed they took part in a variety of activities, one said “There is plenty to do,” and went on to explain how her companion “always wins at dominoes.” St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 13 The home does have visits from ministers of religion and “in house” services for service users. Service user’s bedrooms reflect their personal tastes and contain items that reflect the individuality of the occupant. Visiting relatives were made welcome and had a good relationship with staff members. There is a good assessment of social needs in service users care plans. It is evident from these documents that the service users families are able to contribute to the social care assessment. Service users were seen to be talking to each other as well as the staff. One told the inspector, ”There’s always plenty of people to talk to.” Service users spoke of taking part in recreational activities in the local community. One said, “We go gallivanting; sometimes in a coach to Seaburn. We’ve been across the road, to the hotel, for a Christmas lunch.” Kitchen staff were enthusiastic and said that care staff ascertain service user’s menu choices. The menus are based on traditional home cooked meals appropriate to the age and culture of the service users. The meal that was served was appetising and well presented. Staff were seen to support service users, who needed help, in a sympathetic and relaxed way. This support was always unhurried and focussed on the individual. Service users indicated the food was of a good standard and to their personal taste. Comments such as, “the food is very good: sometimes there’s too much” were typical. A visiting relative also said, “the food is like home made.” St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Service users and most relatives are comfortable about raising issues with staff and the manager. They are sure that issues will be dealt with appropriately by the manager. Staff have had training and have a good awareness of protection issues. The local authoritys strategy, the managers ethical approach and the company’s policy should combine to protect service users. EVIDENCE: The provider’s self-assessment indicates only three complaints have been dealt with in the past year and all of these have been addressed within 28 days. The home has suitable policies. The complaints procedure is available and is displayed in the home. This gives clear information about how, and who complaints can be made to. The information is also in the Service Users Guide. There were few complaints recorded and the manager spoke of seeking early resolutions and dealing with potential problems by having a good level of contact with relatives and service users. One relative who was visiting the home said they were confident that the manager and staff would take up any issues they had and compared this home favourably with a previous care experience. They said, “This is a different world.” Staff receive training in this area and the local authority have a robust adult protection strategy that the staff are aware of. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The home is clean, tidy, and it is well maintained. Bedrooms are well furnished with service user’s possessions and are generally suited to their needs. The home has aids and adaptations, and provides a suitable environment that will meet service users needs and safeguard staff. EVIDENCE: The provider’s self-assessment indicates maintenance is carried out and that there is an ongoing programme of redecoration. At the time of the site visit the home was warm, well ventilated and well decorated. Heating is provided from a safe, low surface-temperature source. No extremes of temperatures were experienced during the inspection. The home has good levels of natural and artificial light in almost all areas but light levels were low outside the hairdressing room. Although it was adequate the décor could be improved in the hairdressing room to make the facility more homely. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 16 All other communal areas are clean, bright, attractive and homely in appearance, are tastefully decorated and furnished with co-ordinating furnishings and curtains, and are domestic and varied in style. Residents are encouraged to bring into the home personal items and furniture of their own. A number of rooms were viewed to confirm this as they were personalised to suit individuals. All were clean, odour free and generally well maintained, although there was some minor damage to boxing around the pipes in some bathrooms. The home provides good levels of equipment, such as hoists and pressure relieving aids. The home also has a number of variable height beds and other equipment, to avoid the routine use of bed rails, and increase the safety of service users. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The number of staff on duty was sufficient to meet service users care needs. The homes recruitment policy and practice safeguards service users. Training is provided and is evident in all practice. EVIDENCE: The provider’s self-assessment confirms training takes place and that 64 of care staff have NVQ level 2 or above. 15 staff are trained in first aid. Staff records indicate training takes place and staff confirm they receive an induction. The manager stated that staff start their NVQ training as soon as they have completed their induction training. The staff on duty were engaged with service users and service users did not have to wait for attention. Care was given in an unhurried manner and call buzzers were answered promptly. Service user’s relatives were complimentary about the staff’s commitment and several said that the staff were good. Recruitment policies and procedures are appropriate. Records indicate that these policies are adhered to and that recruitment is carried out in a safe manner. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is exellent. This judgment has been made using available evidence including a visit to this service. The manager is experienced and competent and the home is well managed. The management team is professional in their approach, committed to the home and well supported by the provider. Service users will benefit from the way the home is managed. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 19 EVIDENCE: The Registered Manager has the appropriate nurse qualifications and experience to manage the home. She has completed the Registered Manager’s Award training. The manager shows a high level of commitment to the home and invests time some of her own time in fund raising and other projects to improve the environment. The manager also says she invests time in hands on care and this ensures she is in touch with the care practice of her staff. The Deputy Manager is also an experienced Registered General Nurse (RGN) and supports the management functions of the Home. Discussions with staff indicate that they have a good awareness of health and safety issues and confirms that they receive training in this area. Staff are enthusiastic about their role and well motivated. Good records are kept of service user’s personal allowance and a random check of balances confirmed the accuracy of records. Quality monitoring systems are in place and are well designed. Service monitoring includes resident questionnaires, residents meetings, staff meetings. Outcomes from surveys are made known in the home’s newsletter. The notes of residents meetings were displayed in the home for information. Documents show that audits of medicines are carried out and complaints and concerns, and falls and accidents are monitored. The manager states that practice is modified in light of the analysis, such as putting more staff in certain areas when falls have been identified as a problem. The manager confirmed that the Provider makes regular visits to the Home, and will commit resources to meet any needs identified by the manager. This is confirmed by the high standard of equipment in the home. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 4 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 x 3 3 3 4 St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP21 Good Practice Recommendations The décor and fittings in the hairdressing room could be made more homely and the light levels in this area should be improved. Minor damage to the boxing around pipes should be made good. St Marks Nursing Home DS0000018197.V329225.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000018197.V329225.R02.S.doc Version 5.2 Page 23 - 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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