Inspection on 08/11/05 for St Mary Magdalene Residential Unit

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Mary Magdalene Residential... 24/04/07

St Mary Magdalene Residential... 06/05/05

St Mary Magdalene Residential... 29/09/04

St Mary Magdalene Residential... 09/06/04

St Mary Magdalene Residential... 29/01/04

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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 Mary Magdalene Residential Unit Claremont Road Newcastle Upon Tyne Tyne & Wear NE2 4NN Lead Inspector Elaine Malloy Announced Inspection 8th November 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 Mary Magdalene Residential Unit DS0000000458.V249214.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 Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Mary Magdalene Residential Unit Address Claremont Road Newcastle Upon Tyne Tyne & Wear NE2 4NN 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 2697920 0191 2697921 st.marymagdalene@btconnect.com St Mary Magdalene & Holy Jesus Trust Mrs Noreen Saxelby Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th May 2005 Brief Description of the Service: St Mary Magdalene is a care home that provides personal care for twenty older people. It is a purpose built two-storey building with a passenger lift. It is situated in a complex of sheltered housing that is run by the same charity and there is a shared kitchen and dining room. All bedrooms are single and one has an en-suite facility. There are suitable lounge and dining areas. Four bathrooms, two with assisted bathing and two showers are provided. The home has grounds with seating. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over 6½ hours. The Inspector talked to residents, a visitor, the manager and staff. Some residents and visitors also completed surveys giving feedback about the service. The areas that the home was asked to improve at the last inspection were checked. The building was toured and a range of records was also inspected. What the service does well: What has improved since the last inspection? Bedrooms and communal rooms have been redecorated. There has been internal promotion to fill senior positions. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 6 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 Mary Magdalene Residential Unit DS0000000458.V249214.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 Mary Magdalene Residential Unit DS0000000458.V249214.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): 3. Resident needs are thoroughly assessed before moving into the home. The admission procedure should be updated to include short stay care. EVIDENCE: Management carry out thorough assessment of care needs before admission. A substantial number of admissions are for respite or emergency care. The home’s admission procedure should be amended to reflect criteria and the assessment process for short stay care. St Mary Magdalene Residential Unit DS0000000458.V249214.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): 9. Some improvements are needed to recording of medication. EVIDENCE: The home uses a monitored dosage system, with medication pre-dispensed into blister packs by the pharmacist. Resident photographs are kept on the packs for identification purposes. Medication is stored in an alarmed room. Room and fridge temperatures are checked daily to ensure safe storage. Records are maintained for delivery, stock checks and returns of medication. Medication records were suitably recorded with the exception of one resident’s medication not being noted as refused. The pharmacist provides pre-printed medication charts. In some instances directions were unclear and needed hand written additions. These were to specify maximum dosage for ‘as required’ medication, and where creams/ointments are to be applied. One resident self-administers their medication. An assessment of the risks had been carried out. This resident is provided with lockable storage in their bedroom. St Mary Magdalene Residential Unit DS0000000458.V249214.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): 13, 14 and 15. Contact with family, friends and the local community is encouraged. Residents are supported to make choices and decisions. Choice of meals is offered and most residents said they like the food provided. EVIDENCE: The home has a visiting policy. Residents are able to receive visitors at any reasonable time, and in private. Contact with the local community is encouraged. Clergy visit the home to see individuals and hold religious services. Relatives and friends involvement is welcomed and twice-yearly meetings (‘Family Forums’) are held. They are also invited to attend or care reviews or if unable, to provide comments. Many residents continue to manage their personal finances. The services of solicitors are retained. Information on advocacy services is available. The extent of personal possessions that can be brought into the home is agreed before admission. Residents have access to their care records and are encouraged to sign their care plans and any disclaimers. Risk assessments are discussed and agreed with residents where necessary. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 11 At the last inspection a Recommendation was made about keeping the practice of frequency of completing food preference sheets under review. This had been actioned. Residents are asked for their choice of meals from the menus a week in advance. Copies are retained and provided to the kitchen. There is scope for residents to change their minds and be provided with alternative meals. This issue had been discussed at a ‘Family Forum’ meeting. It is also included in the questions on food in the home’s quality assurance surveys. St Mary Magdalene Residential Unit DS0000000458.V249214.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): 16 and 18. Residents understand the process for making complaints. There are procedures for protecting residents from abuse and staff receive training. EVIDENCE: The home has a complaints procedure that residents verified they understand. Seven complaints had been made in the last year. Each was responded to within 28 days. Complaints were appropriately recorded and demonstrated action taken. The Manager agreed to make sure that outcomes, for example upheld/partly upheld/not upheld, are documented. A book for compliments is maintained. This included recorded entries and ‘thank you’ cards and letters. There have been no allegations of abuse in the period since the last inspection. The home has policies on abuse, protection of vulnerable adults and ‘whistleblowing’ (informing on bad practice). Staff are provided with relevant training. St Mary Magdalene Residential Unit DS0000000458.V249214.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. The building continues to be kept to a good standard and many areas have recently been redecorated. Longer-term plans for refurbishment are being made. EVIDENCE: In the period since the last inspection bedrooms had been redecorated and had new carpets and window blinds fitted. Communal rooms and the main entrance had also been redecorated. All areas of the home seen were clean, comfortably furnished and suitably equipped. The Manager stated the Registered Person would be contacting the Commission for Social Care Inspection (CSCI) regarding longer-term refurbishment plans for the building. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 14 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 and 29. Good care staffing levels are maintained. The Manager’s supernumerary hours are to be increased and provided consistently. Some improvements are needed to the recruitment process to make sure this is robust. EVIDENCE: At the time of the inspection there were 14 residents, including one person who was receiving respite care. The home operates good staffing levels of 1 senior and 3 carers in the morning, 1 senior and 2 carers in the afternoon and evenings, and 2 carers at night. In recent months a significant number of shifts had included use of agency staff. Vacant carers posts were being advertised following internal promotions. The Manager’s supernumerary hours need to be increased and reorganised. At present she has 48 supernumerary hours monthly, with 24 hours over two weeks of the month. Supernumerary time should be consistently provided each week, at the ratio of one hour per week per resident. Mrs Saxelby agreed to revise rotas and submit to the CSCI. At the last inspection there was an outstanding Requirement. This was for the home’s staff not to be required to take emergency or other calls from service users receiving community care on the complex. Arrangements had been made to set up a link telephone system to a mobile that would enable staff on the St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 15 complex to respond to calls. Unfortunately there had been technical problems on the initial attempt to introduce this system. In the interim staff from the residential home were continuing to receive and log calls. Vacant carers posts were being advertised following internal promotions. A sample of personnel files for staff who were recently appointed was examined. These contained recruitment information including Application form, identification and Criminal Records Bureau checks. One file had only one reference and this was a character reference. Work permit details needed to be followed up. The Inspector also suggested a format be used for recording interviews. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 16 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): 33, 35 and 38. The annual plan for monitoring the quality of the service needs further development. Residents’ personal finances are safeguarded. Thorough checks are carried out to make sure the home meets health and safety requirements. EVIDENCE: The home’s Annual Development Plan does not incorporate the variety of methods for monitoring the quality of the service that happen in practice. Each method should also be measurable by specifying for example the standard and/or frequency. This was discussed with the Manager who agreed to revise the plan accordingly. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 17 Residents spoken with during the inspection gave positive feedback on living in the home. Each said they were well looked after. One resident said she was very happy here. Staff were praised and described as being very kind and that ‘nothing is a bother’ to them. Night staff were said to be good. One resident said staff respond quickly when she alerts them by using the pendant call system. Residents indicated that they are given all the help they need. One resident commented that she could not speak too highly of staff, appreciates their support and still manages to retain her independence. She said she loves the home and would recommend it to anyone considering moving into care. The food was described as being good and residents confirmed they are offered choice of meals. One resident said that there are opportunities to go out with staff accompanying her. A visitor who acts as an advocate for one lady resident said he had found out about the home through its’ reputation. He said he represents his friend at the bi-annual ‘Family Forum’ meetings. He described the home as very good, said he supports the staff and is confident about the care provided. CSCI comment cards were made available to residents and their relatives/visitors to obtain their views on the quality of the service. 11 residents completed and returned CSCI comment cards: 9 said they liked living here and 2 said sometimes; 10 said they feel well cared for and 1 said sometimes; 9 said the staff treat them well and 2 said sometimes; 10 said their privacy is respected and 1 said sometimes; 2 said they wished to be more involved in decision making within the home and 1 said sometimes; 6 said the home provides suitable activities, 1 said sometimes and 5 said it does not; 9 said they like the food, 2 said sometimes and 1 said they do not; 10 said they feel safe here and 1 said they do not; each said if they were unhappy with their care they would know who to speak to. No additional comments were made. No relatives/visitors completed and returned CSCI comment cards. Resident personal finance records were examined. Individual sheets were appropriately recorded with transactions. Each entry had at least two signatures and receipts are obtained for purchases. Regular checks of balances and cash were carried out and recorded. Every six months a thorough audit is conducted to make sure the home is meeting health and safety requirements. This includes policies and procedures, fire precautions, first aid and accidents, the passenger lift, Control Of Substances Hazardous to Health, clinical waste, laundry, food hygiene, medicines, smoking, violence at work, outdoor safety, gas safety, moving and handling, and work and living environment. Risk assessments are recorded concerning individual residents vulnerability. Risk management is incorporated into care plans and regularly reviewed. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 18 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 Regulation 18 Requirement (Requirement outstanding from inspection of 29.9.04) The homes staff must not be required to take emergency or other calls from service users receiving community care on the complex. Medication records must be improved by ensuring: (a) Appropriate completion to indicate where medication is refused (b) Clear directions for maximum dosage of ‘as required’ medication, and application of creams/ointments Deficits to the recruitment process must be addressed, as detailed under Standard 29 in this report. Timescale for action 08/02/06 2 OP9 13(2) 08/11/05 3 OP29 19 08/12/05 St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 20 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 3 Refer to Standard OP3 OP27 OP33 Good Practice Recommendations The admission procedure should be updated to include criteria and assessment process for short stay care. Revised rotas demonstrating the Manager’s supernumerary hours should be submitted to the CSCI. (a) The annual plan for monitoring the quality the service should be developed further (b) Management should address, where possible those negative responses from CSCI comment cards from residents. St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Mary Magdalene Residential Unit DS0000000458.V249214.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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