Inspection on 17/07/08 for St Mary`s Care Home

This inspection was carried out on 17th July 2008.

CSCI found this care home to be providing an Good service.

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

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE St Mary`s Care Home 3 Tooting Bec Gardens London SW16 1HP Lead Inspector Ms Rehema Russell Unannounced Inspection 4:00 17 & 22 July & 1 August 2008 th nd st 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`s Care Home DS0000072033.V367653.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 Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Care Home Address 3 Tooting Bec Gardens London SW16 1HP 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) 020 8677 9677 St Mary’s Care Ltd Manager post vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability (39) of places St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2008 Brief Description of the Service: St. Mary’s Nursing and Residential Care Home is owned by a private company called St. Mary’s Care Limited. The home is registered for 39 places, both nursing and residential care. The home’s stated aims are “to provide excellent quality care to service users” who will be “encouraged to live life to the fullest and given every opportunity to lead as normal a life as possible”. The home is on two levels, with all of the nursing care being provided on the ground floor, and with two passenger lifts connecting the floors. All bedrooms and communal areas are wheelchair accessible. All bedrooms are single and there is a main lounge and dining room on the ground floor and attractive landscaped gardens. The home was formerly run by a religious order and there is a chapel on site where Catholic Mass can still be celebrated. The home is situated in its own grounds with parking space and gardens, a few minutes walk from a main shopping centre that has the full range of community facilities and both rail and bus public transport. For potential service users and interested parties the home supplies a Statement of Purpose, brochure, and verbal information. The deputy manager said that copies of the most recent key inspection report are available in the lounge, staff room and manager’s office. The home’s fees are £548.30 for residential care, £689.00 for nursing care, with an extra £15.00 per week for en-suite rooms. Costs not included in the fee are hairdressing, toiletries, newspapers, private telephone and the charges if a service user chooses to use private healthcare, such as chiropody or physiotherapy, rather than the National Health Service waiting list. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 2 star. This means the people who use this service experience good quality outcomes. The inspector apologises for the lateness of this report, which is being written in mid October 2008. This key inspection was carried out over three days, the majority of it being undertaken on 22nd July 2008, with the remainder finished on 1st August. The inspector spoke with the deputy manager, five service users in depth and several in passing, four visiting relatives, two carers and two cooks. The inspector also looked at records and documentation, the communal areas and several bedrooms. The proprietor came to the home on the 3rd afternoon and the inspector was able to speak with him and accompany him to look at the bedrooms being refurbished and tour the upper floor of the home. At the time of the inspection the home was in a transition period. The Registered Manager had left at the end of April 2008 and the deputy manager had been asked to act up with very little warning and a very brief handover from the departing manager. The proprietor was visiting the home regularly and registered manager from one of the proprietor’s other homes was visiting for one day each week to assist the deputy. The inspector was unable to use the Annual Quality Assurance Assessment (AQAA) form to plan the inspection as the home did not return one. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service, and it also gives the Commission some numerical information about the service. All registered adult care service providers are no legally required to complete an Annual Quality Assurance Assessment and return it to the Commission with 28 days. See Requirement 1. What the service does well: There is a thorough assessment procedure for new service users that ensures their needs and wishes are fully assessed so that the home can be confident of meeting their needs. The home has employed an activities organiser during the week so that daily activities are now provided. Service users said that their privacy and dignity is respected and that staff are friendly. Service user and relatives’ quotes included: • “My bed is comfortable, sheets are changed regularly and the blankets are always clean” DS0000072033.V367653.R01.S.doc Version 5.2 Page 6 St Mary`s Care Home • • • • • • • • • • “I have my own phone and television” “The food is quite good” “The carers do anything I ask, I’m happy here” “The staff are good and caring, but because of not enough my uncle can only have a shower every other day, not daily” “Any complaints made have been addressed” “Care is good, she is always clean but sometimes we have to wait a long time for help” “I like the beautiful gardens” “I am quite happy here, there is plenty to eat, I walk around the gardens and my sister visits” “I wake up at 6.45 am and have tea and biscuits” “They look after us very well here” The proprietors are supportive to the home continuing the spiritual comfort and fulfilment for service users that used to be provided by the previous owners. This means that service users who chose to live in the home because of its previous religious affiliation continue to have their spiritual needs met. 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 Mary`s Care Home DS0000072033.V367653.R01.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 Mary`s Care Home DS0000072033.V367653.R01.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): 1, 2, 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide gives prospective service users most of the information they need to make an informed choice about where to live, but there is some information that needs to be added to each document. Copy of service user contracts/statement of terms and conditions were not available for perusal at the home, and prospective service users and their relatives/friends have opportunities to visit and assess the suitability of the home before admission. A thorough needs assessment is carried out before service users move into the home. The home does not accept service users solely for intermediate care. EVIDENCE: St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 9 The inspector was given copies of the Statement of Purpose and Service Users Guide that had been updated since the registered manager had left the home in April. The inspector studied these after the inspection visits were completed and has found some problems: • Both documents have a name cited under Registered Manager. This person has been appointed as manager for the home but was not in place at the time of the inspection nor, more importantly, have they been registered with the Commission yet. It is therefore misleading to list the person as registered manager at this stage and both documents must be amended accordingly. • The relevant qualifications of any manager/registered manager must be included in the Statement of Purpose • The complaints procedure in the Statement of Purpose and the summary of the complaints procedure in the Service Users Guide should both state the timescale set for the home to respond to complaints. The summary of the complaints procedure in the Service Users Guide is too brief and should be a full summary, not simply a statement as it is currently. • The Service Users Guide states that information regarding (i) terms and conditions of accommodation provided, including the amount and method of payment of fees and (ii) a standard form of contract for the provision of service and facilities by the care home to the service user are too bulky for inclusion and are available to be read in the reception area. However, legislation states that these two pieces of information must be included in the Service Users Guide. The statement of fees can be included as a loose-leaf sheet if the home wishes and the salient points of the contract can be summarised, but both must be provided with the Service Users Guide. See Requirement 2. However, aside from the above points, the Statement of Purpose and Service Users Guide meet all other requirements of legislation and give service users a clear picture of the facilities at the home and the way in which the proprietors wish the service at the home to be provided. The Certificate of Registration displayed in the home was dated 29th January 2003 and was out of date. An up to date Certificate must be obtained and must be displayed in the reception area of the home so that it is visible to service users and visitors. See Requirement 3. The deputy manager assured the inspector that all service users have a contract for staying at the home, however they are now kept at the proprietor’s head office and therefore were unavailable for the inspector to check. At the previous key inspection of 17th July 2007 contracts had been kept in a locked cabinet in the manager’s office and this arrangement should be reinstated so that contracts/copy contracts are readily available for relevant access. See Recommendation 1. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 10 Four sets of needs assessments were checked, 3 for service users who had been admitted in 2008 (2 after the registered manager had left) and 1 of a service user who had been at the home for over 8 years. All four had full preadmission assessments by the home, including a separate nursing assessment as appropriate, as well as pre-admission information obtained from the funding authority if applicable and relevant professionals. At the point of admission therefore, the service user can be confident that their needs have been fully assessed and the home believes it can meet those needs. The home does not admit service users for intermediate care only and so Standard 6 is not applicable. Verbal and documentary evidence demonstrated that the home offers potential service users trial visits, which includes visits by relatives and carers. For example, for one confused service user her son visited the home and chose the room she was to have and another service user visited with her daughter. Visitors spoken with confirmed that they had visited the home with their relative before admission and that a four week trial period is offered. The home does not admit service users for intermediate care only and so Standard 6 is not applicable. St Mary`s Care Home DS0000072033.V367653.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, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans for recently admitted service users are good but those for service users who have been at the home for many years need to be updated and regularly reviewed. Service users health is promoted and maintained. Medication procedures protect service users and three service users selfmedicate, but the reason for any discrepancies must be fully recorded. Service users feel they are treated with respect and their right to privacy upheld, and at the time of death service users and their families are treated with sensitivity and respect. EVIDENCE: Five care plans were assessed, 3 of service users who had been newly admitted to the home and 2 of service users who were admitted over 8 years ago. Each care file seen has a photo, personal details, pre-admission details and activities of daily living (signed and dated). There is then daily holistic care charts, the Holistic Assessment, Intervention and/or Evaluation form, which St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 12 had good clear notes and evidence of follow-up, and the dependency assessment. Care plans cover a full range of needs, such as hearing, mobility, eating/drinking, sleeping, pressure sores, social relationships, health screening, washing/dressing, sexuality, religious belief and each care plan has an evaluation sheet for monthly reviews, and a clinical tool (such as Waterlow) if appropriate. However, the standard of monthly reviews varies. One service user’s care plan had been reviewed monthly, another’s had been reviewed only twice since February 2008, and the care plans of the two service user’s who had been at the home for over 8 years had been reviewed erratically over the past two years, with only 4 reviews over the 8 months of 2008. The home should ensure that care plans for service users that have been at the home for many years are brought up to standard and reviewed monthly. See Recommendation 2. Documentary evidence from care files, and verbal evidence from staff and service users, indicated that service users’ health is promoted and maintained, and that healthcare services are accessed according to assessed need and service user’s choice. For example there was evidence that the home arranged for a service user to access the optician and get new glasses within one month of admission to the home and that a speech and language therapist had been organised for the same service user after a monthly evaluation. Similarly, evidence of referral to chiropody, general practitioner, physiotherapy, the breast clinic, hospital, tissue viability nurse, psychiatrist and Older Persons Team were also seen. Service users confirmed that the local general practitioners visit the home regularly and whenever they are requested. One service user told the inspector that because the chiropodist had not been able to see her since January, she had paid to have a private consultation. The deputy manager continues to check all medication each month when it is received at the home, including checking that all quantities and details recorded by the pharmacist are correct, and also recording any medication to be returned. The previous manager used to conduct a random spot check of medication during the week but the deputy manager has had to reduce this to once a fortnight since she has been acting up. She has however consulted with the pharmacist who has agreed to supply medication in blister packs in the future. At the time of the inspection the deputy manager was undertaking a full tablet check on all medications. Some discrepancies were found but each could be explained by particular circumstances – however, these reasons should have been made clear on medication sheets using the symbols supplied. See Requirement 4. There were no signature gaps in the medication administration charts seen, and the deputy was pleased to report that another service user is now self-medicating, which makes 2 service users altogether. All service users seen were appropriately and well dressed, with good grooming. All bedrooms are single, so there are no shared bedrooms that might infringe privacy, and service users can see visiting professionals in St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 13 private. The inspector was told that 5 service users have private phone lines in their rooms and that all service users are offered a key to their room, although currently only 6 service users have chosen to have one. The home asks relatives to label service users’ clothes so that there is no problem with returning them to the right person from the laundry, and if relatives are unable or unwilling to do it, staff will undertake the task. Relatives said that apart from very occasionally, there were no problems with clothing going missing or being returned to the wrong person. The deputy manager described how end of life care had been given recently to one service user who had been sent to the home from hospital. The home had worked closely with St. Christopher’s Hospice, who had given staff training in the use of syringe drivers. The service user was given one to one care and although there were no relatives, there were several friends who visited. The deputy manager also described how the service user’s death and removal from the home had been handled, and this was in a sensitive and respectful way, including calling religious sisters to undertake prayers. St Mary`s Care Home DS0000072033.V367653.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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides for the social and spiritual preferences of service users and provides daily activities. Service users are encouraged and facilitated to maintain contact with family and friends, and are helped to exercise choice and control over their lives. A well balanced diet is provided in pleasing surroundings. EVIDENCE: The home has employed an ex-care worker into the role of full-time activities organiser. She currently organised bingo, colouring, films, ball games and exercises, and on one of the inspection days was dancing in the lounge with a service user, who had spontaneously asked her to in response to the music being played. The activities organiser does not work at weekends but the deputy manager said that care workers carry out activities on Saturday and Sunday. The inspector was also told that a daily newspaper is obtained for each service user. There are also outside entertainers who visit the home and St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 15 the proprietors had recently held a popular barbecue, which service users spoke well of to the inspector. The home is welcoming and supportive of service users’ religious observation. As it was formerly a home run by a Catholic congregation there is a high percentage of Catholic service users. The new Proprietors have respected this by continuing to support the use of the purpose-build Chapel in the home, and by continuing to encourage and support members of the previous congregation to visit the home to give service users daily Communion and spiritual comfort. The home is also open and supportive of ministers/lay persons of any other religion visiting the home. There are no restrictions on visiting at the home and service users may have visitors in the lounge and seating areas in the outside garden, or privately in their room or the small lounge on the ground floor. The inspector spoke with two sets of relatives who were visiting service users at the home. One set said that the staff are “very good and caring” and that if they have any complaints, these are always addressed. They did say however that their relative was only able to have a shower every other day because their were not enough staff to assist him with a daily shower. The other set of relatives were also happy with the home, saying it provided “good care” and “is always clean”. However, they added that sometimes there was a long wait before help arrived. Verbal and documentary evidence indicated that routines at the home are flexible and that service users’ choice is respected. For example, it was noted in one care plan seen that the Proprietors of the home had said that the service user must be given a bath whenever he requested it, even if this meant daily. Service users are able to get up at various times in the morning, to have breakfast in their rooms if they wish and to have alternative dishes at mealtimes. The inspector saw a number of service users’ bedrooms. All were personalised according to the individual’s taste, several contained a chair or small item of furniture from their own home and almost all contained a variety of personal ornamentation and framed pictures. The home’s menu system consists of four weekly rotating menus. The main meal each day is three courses at lunchtime, and there is always an alternative cooked choice each day. On the first afternoon of the inspection food had been left out by the cook for the evening cook to prepare and it seemed to be a sparse amount to the inspector. However, on subsequent inspection days at lunchtimes there was plenty of food, well cooked with fresh ingredients and home made desserts, and attractively laid out tables. The inspector asked several service users about the food in the home and their opinions were: “the food is quite good” and “there is plenty to eat”. Service users said that the breakfasts and lunches were good and were varied, but that the suppers are not as good with little choice. There was a wealth of choices observed during St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 16 lunchtime, including fried cod, fried eggs, minced beef, ham salad, salmon salad with potatoes, and macaroni cheese. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 17 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. Complaints are listened to but evidence must be kept at the home. Service users are protected from abuse. EVIDENCE: The deputy manager said that the home had received one formal complaint since the previous inspection of 17th July 2007 but that all the papers had been sent the Proprietors. The complaints file in the home therefore showed no evidence of this complaint so the inspector was unable to determine whether it was being dealt with in accordance with regulation. Details of the complaint and its investigation must therefore be sent to the Commission, and the home must ensure that a record of all complaints is maintained at the home at all times. See Requirement 5. However apart from this, as previously stated relatives told the inspector that any concerns/complaints raised were always dealt with. At the previous key inspection of 17th July 2007 the inspector was told that abuse training is given as part of induction and that a new training session was planned which everyone would attend. After the current inspection the Internal Auditor/Trainer sent the Commission a copy of the home’s 2008 matrix, however this showed that only 5 staff had attended adult protection training this year, all of whom are none-care staff. The majority of care staff St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 18 have NVQ 2 and have therefore acquired knowledge of safeguarding adults through this, however the Internal Auditor/Trainer should find out whether a specific course on abuse is still necessary, and if so, make suitable arrangements for all care staff, including nursing staff, to attend one. See Recommendation 3. The deputy manager was fully conversant with the different types of abuse and the procedure that must be followed should abuse be suspected/reported. A safeguarding enquiry was raised by social services in June 2008 regarding the care of a service user who has deteriorating mental health, but at the time of writing this report the results of the enquiry were not yet known. The home does not retain any valuables or monies for service users. The one exception is that since her mental health has deteriorated resulting in changed behaviour, the home is temporarily storing essential documentation and money books for one service user. As the inspector did not inspect the complaints and abuse policies during the inspection, a copy of these should be sent to the Commission. See Recommendation 4. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 19 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, 20, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The grounds of the home are attractive and well kept and the indoor environment is homely and being improved by the new proprietors. Bedrooms are comfortable and personalised by service users’ own possessions. The home is well lit, heated and ventilated. The home is clean and hygienic, with the exception of the floor of the ground floor kitchenette. EVIDENCE: The location and layout of the home is suitable for its purpose and it is accessible, safe and homely. There are well kept, attractive and accessible grounds which service users and visitors were enjoying on the days of the inspection. One service user told the inspector that she makes a point of taking St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 20 a walk in the garden each day, and other service users and visitors also said how much they enjoyed the garden facilities. For several years prior to the changeover to the current provider in January 2007 the home was in need of refurbishment in several areas. The new Proprietors have made several improvements to the home and the main lounge is not comfortable and homely, with a huge flat screen television which makes visibility easy wherever service users are sitting in the lounge. The Proprietors have started refurbishing the top floor of the vacant wing of the home into large single bedrooms with en-suites. The previous report recommended that the Proprietors considered having a separate, equipped hairdressing room rather than hairdressing taking place in the main lounge. See Recommendation 5. The home has a dining room where service users can choose to eat meals. Service users are able to choose where to sit from several tables, which were all attractively laid out at lunchtimes. The dining room has windows on one side and a glass panelled wall on the other, which means there are views and day light from both sides of the room, making it an attractive and light. Several bedrooms were seen during the inspection. All those seen were larger than minimum size and several had en-suite rooms with toilet and washbasin. All bedrooms were personalised, according to the service user’s individual tastes and interests, and all linens and fittings seen were of good quality. Several service users had brought in an item of furniture and ornamentation from their previous homes. Several bedrooms have been redecorated and the providers have plans to redecorate and upgrade all bedrooms. No problems were found with heating, lighting, water supply or ventilation at the inspection. On the days of inspection areas of the home seen were clean and hygienic, and no problems were found with the laundry facilities. There is a small kitchenette on the ground floor which is used by staff to make service users and visitors tea. The floor covering of the kitchenette is damaged and difficult to keep clean. The proprietors plan to replace the flooring and it is recommended that this is done as soon as possible to prevent any possible hygiene problems. See Recommendation 6. This recommendation was also made following the inspection of 27th July 2007 and repeated following the random inspection of 30th January 2008. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skills mix of staff, and are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. The new proprietors are in the process of implementing a training programme EVIDENCE: Rotas for nurses, care workers, night staff and ancillary staff were seen. They evidenced that there are always 2 Registered General Nurses (RGNs) and 5 care assistants on early shifts, 1 RGN and 4 care assistants on late/evening shifts and 1 RGN and 3 care assistants on night shifts. There are also 8 ancillary staff on day shifts, 3 on evening shifts. The home is on two levels, so the rota allows for one first level nurse present on each floor on early/day shifts, and one first level nurse present on the ground/nursing floor during the night. When the new Proprietors took over the home, all care workers were employed on part-time hours (22 hours per week). They have tried to standardised employment practices and most care assistants are now on full-time hours. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 22 However, the majority of nurses currently remain on part-time hours, which can cause difficulties with rostering. All nurses employed by the home are level 1 Registered General Nurses and so are able to be the nurse in charge when on duty. Information supplied by the Auditor/Trainer shows that of the 26 care assistants employed, 14 have obtained NVQ Level 2 and so the home has exceeded the 2005 recommended qualification target. Three recruitment files were seen of two care assistants and one housekeeper, who had been employed since the previous inspection of 30th January 2008. All documentation was in order, with one exception, and each employee had had Criminal Records Bureau check, including POVA First when appropriate. The one exception was that the 2 references for the housekeeper were not on file, but the deputy manager said she had seen them but they were awaiting filing. The Proprietors have employed an Auditor and Internal Trainer who is organising training and quality assurance at the home and who is an assessor for NVQ levels 2 and 3. In July 2007 the inspector was told that a training plan had been put into place to ensure that all staff have undertaken every mandatory course by September 2007, and that all care staff who do not have NVQ Level 2 will attain it, including domestic staff. The NVQ training was intended to be internally funded so that staff do not have to pay for it themselves, which is very good practice. The training plan intention is that once all mandatory training is completed and all staff needing NVQ Level 2 have enrolled, then a programme to ensure that staff undertake nonmandatory but very important training in areas such as dementia awareness, hazardous substances, infection control and death, dying & bereavement will be implemented. After the current inspection the inspector was sent a copy of the staff training matrix compiled so far. It appeared to show that the home was still at the beginning of the programme, with all staff updating all mandatory courses. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 23 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, 33, 35, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager post is currently vacant. There is a quality assurance system which needs to be fully established and evidenced. Service users financial interests are safeguarded. Documentation at the home needs to be improved, including the policy manual for staff reference. The health, safety and welfare of service users is generally promoted but evidence of certain health & safety requirements could not be located and must be sent to the Commission. EVIDENCE: St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 24 As stated at the beginning of the report, the Registered Manager left the home at the end of April 2008 and the deputy manager had been asked to act up with very little warning and a very brief handover from the departing manager. A further difficulty for the deputy manager was that she is a fairly recent employee of the home compared to most of the nurses and who have been at the home for many years. However, the proprietor visits the home regularly and a registered manager from one of the proprietor’s other homes has been visiting for one day each week to assist the deputy. The inspector was told that the Proprietors have appointed a new manager, who would be starting full time at the home from the end of September 2008. The Registered Provider must ensure that the new manager applies to the Commission for registration as soon as possible. See Requirement 6. Regulation 26 visits and reports are carried out by the Auditor/Trainer, and copies of the reports written for 7 of the first 8 months of 2008 were sent to the inspector after the inspection. They are clearly written, with recommendations where appropriate. At the previous key inspection of 17th July 2007 the inspector was shown a blank example of the service users’ and visitors’ satisfaction questionnaires that were intended to be used six monthly, and form part of the quality assurance system at the home. However, at this inspection no evidence of completed questionnaires was available. The Auditor/Training should provide the Commission with evidence that this system is being implemented, see Recommendation 7, and the recommendation made at the previous key inspection for a summary of surveys to be available annually is repeated. See Recommendation 8. The inspector was shown the Policy & Procedure Manual. This is a huge file, which had been updated in February 2008, however there were no page numbers and it was difficult to navigate through the manual or to find any particular policy. It is recommended therefore that this file is broken down into a more workable document, and that policies and pages are numbered and indexed for ease of use. The following health & safety documentation was seen: • • • • • • • Fire Risk Assessment, dated 2008 Food Hygiene assessment, dated March 2008 Nurse call system service, dated May 2008 Hoists service, dated November 2007 Hazardous waste check, dated January 2008 PAT tests, dated end of January 2008 Weekly call points Subsequent to the inspection the Auditor/Trainer provided a photocopy of the fire instruction and drill record. This evidenced that fire activity had been carried out on 13/3/08, 8/2/08, 4/6/08 and 29/7/08. However there was no St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 25 explanation of what the activity was, nor who attended it. Fire records must be more explicit, so that a full record of fire drills is maintained. See Requirement 7 . The home must also provided evidence of a five yearly electricity safety certificate, an annual gas safety certificate, regular servicing of boilers and central heating systems, regulation of water temperatures and health & safety risk assessments, none of which were available at the home for perusal. See Requirement 8. St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 26 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP33 Regulation 24 Requirement The Registered Person must ensure that the AQAA information required by the Commission is provided, and that in future it is provided within the timescale set. The Registered Person must ensure that all of the information required by legislation is present in the Statement of Purpose and Service Users Guide. The reasons for any medication discrepancies must be made clear on Medication Administration Records using the symbols supplied A record of complaints received must be kept at the home at all times. The Registered Provider must ensure that the appointed manager applies for registration as soon as possible. Records of fire drills must evidence the type of drill and who attended it. Evidence of health and safety conformity, as cited under Management and DS0000072033.V367653.R01.S.doc Timescale for action 30/11/08 2 OP1 4&5 31/12/08 4 OP9 13 (2) 30/11/08 5 6 OP16 OP31 17 (2) 8 30/11/08 30/11/08 7 8 OP38 OP38 23 (4) 13(3)(4) & (4)(c) 30/11/08 30/11/08 St Mary`s Care Home Version 5.2 Page 28 Administration in this report, must be provided. RECOMMENDATIONS1 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 4 5 6 Refer to Standard OP2 OP7 OP18 OP16 OP18 OP19 OP19 Good Practice Recommendations Contracts or copy contracts should be maintained at the home for perusal by interested parties. Care plans for service users who have been at the home for several years should be brought up to standard and reviewed monthly. Suitable arrangements should be made for all staff to attend abuse training/update training, if they have not already done so. Copies of the home’s complaints procedure and abuse policy should be sent to the Commission. This recommendation is outstanding since July 2007. The Registered Person should consider providing a separate hairdressing room when carrying out the refurbishment of the home. The floor of the ground floor kitchenette should be replaced as soon as possible to prevent any hygiene/health and safety problems. This recommendation is outstanding since July 2007. The home should provide evidence that it is carrying out the six monthly service user and visitor questionnaires planned as part of the quality assurance system. Service users’ views should be summarised annually and made available to current and prospective service users 7 8 OP33 OP33 St Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Mary`s Care Home DS0000072033.V367653.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!