Inspection on 15/09/05 for St Martha's Residential Home

This inspection was carried out on 15th September 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 Martha's Residential Home 12/11/08

St Martha's Residential Home 14/11/07

St Martha's Residential Home 26/09/06

St Martha's Residential Home 08/02/06

St Martha's Residential Home 05/10/04

St Martha's Residential Home 10/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Marthas Residential Home 17 Thornhill Park Sunderland SR2 7LA Lead Inspector Mr Clifford Renwick Unannounced Inspection 15th September 2005 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 Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Marthas Residential Home Address 17 Thornhill Park Sunderland SR2 7LA 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 565 6443 0191 510 8810 Ms Gwendoline Swalwell Care Home 24 Category(ies) of Dementia (8), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (24) St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager is to complete the Registered Managers Qualification successfully. 5th October 2004 Date of last inspection Brief Description of the Service: The home provides care to older people over the age of 65 years some of who may have dementia or mental health needs. It provides personal care only and any health needs are dealt with by the Community Nursing Services. It is not registered to provide care for people with a physical disability. The home also provides a day care service in a separate designated area of the home, a domiciliary care agency as well as a meals at home service none of which impinge upon the care home. The house is Victorian in construction and three storeys high with most of the bedrooms being on the upper floors. The house is semi detached and extensions over the years have been added. There is a large garden and paved terrace area to the front of the home with an arrangement of seating that can be used by the service users and their visitors. The home is sited in a quiet tree lined street, which has a number of other residential and educational facilities in close vicinity. It is only a short walk into the City Centre where there are a range of services and shops. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.5 hours and was carried out as part of the statutory twice-yearly inspection process. Selected areas of the premises were viewed which included all communal areas, six bedrooms and the newly refurbished areas which included the day care facility and the domiciliary care office. A range of records were examined which included residents care records as well as records that related to health and safety and staff employed in the home. Discussion took place staff and also with residents and lunch was taken with three residents. Time was spent observing staff practices. It was established in discussion that the people who live in this home prefer to be known as residents and this term of reference is used throughout the report. The judgements made are based on the evidence available at the time of the inspection. What the service does well: What has improved since the last inspection? St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 6 Improvements have been made to the interior of the building with new lounge chairs, carpets on stairways and new furniture in the dining room. Part of the refurbishment has also included a separate hairdressing facility and also a new communal specifically for those residents who have dementia type needs. Improvements have also been made to bathrooms and the creation of a paved terrace to the front of the home offers residents a safe and pleasant facility to use during the warmer weather. Staffing levels have increased and this has ensured that residents are supported by sufficient numbers of staff at all times. The introduction of the two meal sittings is a positive step and has ensured that staff have plenty of time to offer individual support to residents during the meal time making the meal times a relaxed and pleasant experience. 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 Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Full information is not available to prospective residents therefore they are not able to make an informed decision as to whether or not to move into the home. Residents are not issued with a contract showing the terms and conditions of residence therefore they are not informed of their terms and conditions of occupancy. EVIDENCE: Discussion held with the owner confirmed that since the last inspection the Statement of Purpose and Service User Guide had been completed in conjunction with a homes brochure. This was currently stored on a computer which was undergoing repair so it was not possible to access these documents at the time of the inspection. Similarly residents contracts/terms and conditions of residence had been amended as advised at the last inspection but these too were stored on the computer and not available for examination. Examination of residents case files confirmed that the amended contracts had not been issued. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Residents care plans are in place, but do not fully reflect their observed needs. This can limit the guidance available regarding care practice and consistency. Medication arrangements take a considerable proportion of the senior care workers time, but administration and recording arrangements are appropriately managed, which will ensure that service users receive their medication as prescribed by their GP. EVIDENCE: Examination of care plans for three residents confirmed that further developments are needed particularly where staff are supporting residents with pressure care and appropriate nutrition involving fluids and food. The care plans are not always specific in that they do not detail the actions that are being carried out by staff to meet residents assessed needs though discussion held with staff confirmed that they are fully aware of the actions to take. A good practice of senior staff in relation to people who move into the home is the practice of carrying out a full inventory of any prescribed medication that they bring with them followed by an immediate review with the GP. Records to demonstrate this were in place. Discussion was held with the owner about the general procedures for then ordering of the monthly prescribed medications for all residents and this is addressed as a requirement of this report. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Social activities both in and outside of the home are well managed enabling residents to make positive choices about how they spend their day and friends and families are very much a part of this process. The meals services are good and residents are involved menu planning. This contributes to the promotion of healthy eating. EVIDENCE: At the time of the inspection a number of the residents were attending Holy Communion while others were involved with the activities coordinator making Christmas decorations. The activities coordinator who works 4 hours per day Monday to Friday is active in organising activities that residents enjoy as well as matching their individual abilities. Recent social events that had been held in the home were a barbeque with an entertainer who played the accordion. Discussion with the residents confirmed that this had been an enjoyable event. In addition to this a number of the residents had returned from a pilgrimage to Lourdes which again they stated had been most enjoyable. A forthcoming trip was planned to visit the Eden camp which is a former prisoner of war camp now operating as a wartime museum. The residents in discussion confirmed that they are looking forward to this. In addition to this some residents continue to attend and “over 60’s” club in the community. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 11 Two sittings are now held for lunch and this enables staff to offer individual support to residents in an unhurried manner. Lunch was taken with the residents and this was an enjoyable experience. The food was well presented, hot and tasty and sufficient in quantity. Discussions held with the residents confirmed that the food is always nice and there is always sufficient to eat. The new tables and dining room chairs and how tables were presented made eating in the home a pleasurable experience. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 There are policies and procedures in place in relation to prevention of abuse which ensure the safety of residents. EVIDENCE: Discussion was held with the manager about an incident which is currently being addressed and relates to staff conduct. The manager was advised of the need to refer these matters to the appropriate persons such as the local authority and the commission in relation to the protocols in place for dealing with suspected abuse. The owner is currently addressing this incident using employment procedures in accordance with the Employment at Work Act. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 26 The home is clean, warm and well maintained offering residents a homely and safe environment in which to live. Improvements have been to the building which ensures that residents needs are met. However the exterior of the building needs to be fully decorated. EVIDENCE: The inspection focused upon all of the upgrading and refurbishment which has been taking place over the last 6 months. These works have resulted in improved communal lounge spaces for the residents as well as improved and separate facilities for both the day care and domiciliary care service which operates from the same premises. Part of these refurbishment shave included the creation of a paved terrace and seating area to the front of the home that is used by the residents and offers a nice place to sit when the weather is warm. Decoration is being carried out to the exterior of the home and this has been delayed by the weather. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 14 A hairdressing facility has also been created which offers the residents a place to have their styled without imposing on any of the other facilities within the home. At the time of the inspection a leak had developed in the entrance porch and this was discussed with the owner as well as some minor matters relating to some cracked windows. Assurances were offered by the owner that work was in hand to address these matters once the heavy rain had subsided. The home was clean and tidy and there were no noticeable hazards at the time of the inspection. Discussion held with a resident who had recently moved into the home confirmed that they had been supported to bring with them a range of personal possessions in order to personalise their bedrooms. Those rooms which were viewed had been personalised and where rooms where shared appropriate screening was in place to support the privacy and dignity of residents. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 Staffing levels are sufficient to effectively meet the needs of residents living in the home. The deployment and number of staff on all shifts ensures that at all times residents are supported by an experienced group of staff, although this would be enhanced by staff having a planned training programme which demonstrates ongoing training and which includes specialist training in caring for people with dementia. EVIDENCE: Examination of staffing rotas confirmed that agreed staffing levels are maintained in the home. The manager is in the process of recruiting new staff and is awaiting criminal record bureau checks before offering employment in the home. Staffing numbers have been increased and this has resulted in additional housekeepers being employed. One of the two members of staff who work as assistant managers is currently undergoing NVQ Level 3 training. All staff who are responsible for administering medicines have received certificated training in the safe handling of medicines. All staff had received fire training by the fire officer the day before the inspection. A training plan is in place which records what training staff have undertaken and what training is required however there is no annual training plan to show how future training needs will be addressed. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 16 Observations made throughout the inspection confirmed that staff carry out their work in a professional manner and there is a good rapport between residents and staff. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 The owner offers clear leadership and direction to the staff so that they can consistently meet the needs of residents. Views of the residents are sought in order that they can contribute to the development of the service. The health and safety of the service users is promoted by a well managed staff team. EVIDENCE: Since the last inspection the registered manager has ceased to work in the home and the owner has assumed full responsibility for the day to day management of the service. The owner is supported by two members of staff who work as assistant managers and whose working week on the rota is designed to ensure that there is always at least one of them on duty to ensure that there is management support to the staff. Both of the assistant managers spend one day that is allocated to record keeping and ensuring that records which relate to residents care are kept up to date. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 18 The owner is continuing to develop quality assurance systems within the home and one aspect of this has been the introduction on the weekly health and safety meetings. Any concerns raised at this meeting are addressed and followed up at the next meeting to ensure actions have been taken. In addition to this staff have been allocated responsibility for each floor of the home and are responsible for maintaining health and safety. Minutes available for examination confirmed that this is a positive approach to addressing and reviewing health and safety matters within the home. As part of the quality assurance systems residents views are sought during the review process to ensure that they can contribute to the service. Appropriate records are in place which confirm that staff receive regular fire instruction and fire drill training. Part of the refurbishment of the premises included extending and improving the fire alarm/fire detection systems and also the resident emergency call system. St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 X 3 X 3 2 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 20 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 Standard OP1 Regulation 4, 5 Requirement The Statement of Purpose and Service User Guide must be implemented with a copy being issued to residents. A copy must also be submitted to the commission. A copy of the terms and conditions of residence must be issued to each resident. A blank copy of this document must also be submitted to the commission. Residents care plans must continue to be developed as advised within this report. The exterior of the premises must be decorated and all remedial/repair works as discussed during the inspection must be addressed. An annual staff training plan which includes specialist training in dementia type illnesses must be implemented. Timescale for action 31/12/05 2 OP2 5 31/12/05 3 4 OP7 OP19 14 23 31/03/06 31/12/05 5 OP30 18, c, i 31/12/05 St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Marthas Residential Home DS0000015725.V250048.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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