Inspection on 21/04/05 for St Mary`s Care Home

This inspection was carried out on 21st April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Mary`s Care Home 29/05/07

St Mary`s Care Home 27/06/06

St Mary`s Care Home 07/12/05

St Mary`s Care Home 10/12/04

St Mary`s Care Home 22/04/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Marys Care Home Church Chare Chester Le Street Durham DH3 3PZ Lead Inspector Rachel Dean Unannounced 14 & 21st April 2005 th 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 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 Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Marys Care Home Address Church Chare Chester Le Street Durham DH3 3PZ 0191 3890566 0191 3882806 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Carewell Healthcare Limited Mrs Maureem Pricilla Garrett CRH 54 Category(ies) of OP Old age (54) registration, with number PD Physical disability (2) of places TI Terminally ill (3) St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Terminal Illness. Up to 3 persons with a terminal illness (palliative care) over the age of 55 may be accommodated commensurate with the home`s Statement of Purpose and where appropriately qualified and competent staff are provided. Physical Disability. p to 2 persons with a physical disability, over the age of 55, may be accommodated commensurate with the home`s statement of purpose. Date of last inspection 10th December 2004 Brief Description of the Service: St Mary’s is a purpose built care home. It is registered to provide personal and nursing care for up to fifty-four older people. The home is also registered to provide care for up to two younger adults with physical disabilities whose needs are primarily those of an older person, and up to three people who have special needs due to a terminal illness. Fifty-two of the bedrooms are single occupancy, four of which have en-suite toilet and washing facilities. One larger bedroom is used as a double bedroom. Communal space is located throughout the home with a selection of lounge areas, quiet rooms and dining facilities. Downstairs a conservatory area leads out into an enclosed courtyard garden. Eight bathrooms, four shower facilities and forteen toilets are appropriately placed throughout the home. The home is located in Chester-le-Street, close to the local high street with shops and amenities. St Mary’s has close links with four local GP practices, enabling residents to keep their own GP where possible. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of St Mary’s Nursing Home, taking place over two days. This inspection looked at a number of important areas, such as new admissions, how personal and health care is provided, arrangements for helping people with medication, what meals are provided and how complaints are handled by staff. During this inspection interviews were held with five service users, two relatives, four members of staff and the manager of the home. Comment cards and reply paid envelopes were given to the manager of the home for distribution to service users and relative, but at the time that this report was written none had been returned. The cases of three service users were looked at in detail, including the inspection of the records kept by the home. A partial tour was made of the premises and observations were made throughout the two days of the inspection. What the service does well: What has improved since the last inspection? Although the home’s environment was not fully assessed during this inspection, it was evident that communal areas of the home had been decorated and re-carpeted and looked much smarter than during previous inspections. It was also noticeable that service users room were now being decorated in more individual ways. This has created much more homely, comfortable and pleasant surroundings for service users. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 6 In addition to improvements to the décor in the home there has been an improvement in the monthly management reports that are done by senior managers visiting the home. These reports are now completed on a more regular basis and include monitoring the progress made by the home towards meeting requirements and recommendations made during inspections. This is important in ensuring that service users at St Mary’s receive good care and are kept safe in the home. 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 Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 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 standard(s) 3 Before admission to St Mary’s information is gathered about each prospective service users needs, ensuring that the home can meet their needs and has in place any specialist equipment needed for their care. EVIDENCE: During this inspection discussions with relatives indicated that they were able to visit the home several times before making a decision about its suitability and that the manager had spent time with them finding out about their relatives needs. Discussions with service users confirmed this. Observation of records showed that information about prospective service users was gathered from a range of sources before admission, including social services, hospitals, relatives and visits to the person themselves by a senior member of the home’s staff. Two of the service users whose cases were looked at in detail during the inspection needed ‘nursing’ care and had received an assessment of their entitlement to free nursing care. Records of this assessment were available in their records. St Mary’s does not provide intermediate care, so the assessment of Standard 6 was not necessary. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10 All service users living at St Mary’s have an individual plan of care, setting out and recording their health and social care needs. However, the information in some plans would benefit from being more detailed and being updated more often, to ensure that they provide staff with clear guidance on how to meet each individuals needs. The health needs of service users are met at St Mary’s ,with advice and support sought from doctors, nurses and other health professionals when required. Medication is managed appropriately at St Mary’s, with regular checks and audits made by the nursing staff to ensure that medication is stored and administered safely. Personal support in the home is provided in ways that promote and protect service users’ privacy and dignity, although more information could be included in care documentation about what service users are able to do for themselves or with support, in order to maximise their independence and control. EVIDENCE: St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 10 During this inspection the care plans and records kept for three service users were looked at in detail. Each plan of care was found to contain detailed information that was relevant to each person’s individual circumstances, with evidence of regular reviews and risk assessments. There was also evidence of regular input from doctors, district nurses and other health professionals for advice and support when required. However, the plans could be developed to contain more detail about each individual needs, particularly the things that each individual can do for themselves or with support, to ensure that as much independence as possible is maintained. The current system for recording manual handling risk assessments needs to be improved, since the ones observed during the inspection were not completed very well. Changes in need were recorded in the monthly reviews, but were not always reflected in the plans of intervention. This meant that anyone reading the plans would have to read though all of the reviews to ensure that they were fully up to date which could lead to confusion among staff about peoples care needs. During the last inspection it was recommended that ways of involving service users (or their representatives) in the care planning process, and ways of evidencing this involvement (for example, service user signatures) be developed. This area still needs to be developed. A selection of medication records and storage arrangements were inspected and found to be appropriate, with all medication administered by trained nursing staff and regular checks and audits carried out. On the day of this inspection the treatment room was very warm (26oC), raising concerns about the safe temperature parameters for storing medication. As a result of this it has been recommended that the temperature of the treatment room be monitored and any necessary action taken to ensure that the room is maintained at an appropriate temperature for the safe storage of medicines. Observations made during the inspection and discussions with service users and their relatives indicated that staff are pleasant, friendly and caring, treating service user with respect at all times. If staff do not treat service users with respect the manager demonstrated that firm disciplinary action is taken against the staff member concerned. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 11 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 standard(s) 12, 13, 14 & 15 A lively activities programme is provided at St Mary’s with the input of two activities coordinators, ensuring that service users have the opportunity to join in with a wide range of social and recreational activities. Visitors are made to feel welcome at St Mary’s, with no restrictions on visiting times and relatives encouraged to stay for meals and join in with social events and outings. St Mary’s provides some flexibility and choice in daily routines, although more information could be included in care documentation about how service users want their care to be delivered, in order to maximise their independence, choice and control. A nutritious and varied diet is provided at St Mary’s, with the majority of food and cakes cooked on the premises and special needs catered for in an imaginative way. EVIDENCE: Two activities coordinators are employed at St Mary’s on a ‘job share’ basis and have developed an imaginative programme of activities, including big events like day trips and weekly bus trips, clothes parties, birthday and special events parties (such as VE day celebrations), monthly entertainers, coffee mornings and fundraising events. There is also a programme of ‘day to day’ St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 12 activities, such as twice weekly chair exercise classes, bingo, reminiscence, quizzes, clergy visits, walks in the park, arts and crafts, sing-a-longs, ‘one to one’ time, videos and games. Individual records of each service users social history, interests, and likes and dislikes are being developed, including a record of the activities that the person has joined in with. Discussions with service users and relatives indicated that the atmosphere at St Mary’s was usually active and lively, with activities regularly going on. Relatives commented that there were no restrictions on visiting and that they were always made to feel welcome, with tea and biscuits always offered and the choice of staying for meals available. One family commented how nice it had been to be invited to stay for tea with their relative on the evening of her admission. St Mary’s is a nursing home that provides care for up to 54 older people, some of whom have very complex needs. As a result of this it can be difficult to actively promote autonomy and choice for all service users. A choice of meals and regular refreshments is offered and individual routines are kept flexible. However, this was more difficult to evidence for those service users who could not express their wishes or feelings. As a result of this it is recommended that more information could be included in care documentation about how service users want their care to be delivered, in order to maximise their independence, choice and control. Relatives and service users made positive comments, such as ‘excellent’ and ‘tip top’, about the food provided at St Mary’s. Staff had been trained on providing good nutrition to older people and this was evident from the menus available, the provision of nutritious dietary supplements (including homemade milkshakes and smoothies) and the way special needs were catered for. Soft diets were managed in an imaginative way, that enabled people to maintain a nutritious and varied diet, including being able to have homemade cakes. During the last inspection a recommendation about promoting peoples independence at meal times was made. Since then a selection of specialist cutlery and plate guards have been purchased by the home and this had enabled some service users feed themselves more effectively and without embarrassment. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 13 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 standard(s) 16 & 18 Appropriate policies and procedures are in place for the handling of complaints and the protection of service users from abuse, with service users being protected from abuse and any reported concerns being dealt with quickly and effectively. EVIDENCE: Appropriate complaints policies and procedures are in place at St Mary’s, with records kept of each complaint made and the action taken to rectify it. These records and discussions with relatives and service users indicated that the manager is approachable and that complaints and concerns are taken seriously in the home. However, at the time of this inspection an incident came to light where a service user and their relative had not reported concerns that had later been reported by a staff member and dealt with effectively. As a result of this incident it is recommended that the complaints policy and procedure be proactively promoted at St Mary’s to ensure that all service users and their relatives feel comfortable about raising concerns. Appropriate adult protection policies and procedures are in place at St Mary’s. During this inspection these policies and procedures were followed in practice, with the manager informing the appropriate authorities and then taking appropriate disciplinary action against the individual concerned. Following this incident it is required that the procedures for referring an individual to the POVA list be written up and added to the home’s existing adult protection policies and procedure. The manager indicated that it was planned to provide staff with update training in adult protection and whistle blowing as a follow up to the incident. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 14 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 standard(s) These standards were not fully assessed during this inspection. EVIDENCE: Although this area was not fully assessed during this inspection there has been a notable improvement in the décor and maintenance of the home over the last year, with service user rooms being decorated in a more individual way and communal areas having been decorated and re-carpeted. However, the recommendation made during the last inspection about the ventilation arrangements in one of the upstairs bathrooms remains outstanding and should be addressed. Since the last inspection action has been take to limit service user access to an unsafe area of the homes grounds, with an attractive metal gate having been put in place. It has been necessary to make a requirement regarding the provision of storage space in the home. During this inspection it was found that spare equipment was being stored in three different lounge areas, bathrooms and corridors. This situation is limiting service users and staff’s access to the home’s communal space and facilities and must be addressed. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Since the last inspection all records of financial transactions are now countersigned to ensure the protection of staff and service users. There has also been an improvement in the frequency and content of the monthly management reports that are being completed by the responsible individuals representative. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 18 No 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 18 Regulation 13(6) Timescale for action It is required that the procedures 30th May for referring an individual to the 2005 POVA list are written up and added to the home’s existing adult protection policies and procedure. It is required that storage 31st provision in St Marys be August reviewed and additional storage 2005 space provided so that equipment (such as spare beds, mattresses and spare walking equipment) is not stored in communal areas. Requirement 2. 19 23(2)(l) 3. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations It is recommended that ways of involving service users (or their representatives) in the care planning process, and ways of evidencing this involvement (for example, service user signatures) be developed. This recommendation remains outstanding from the previous inspection. It is recommended that the current practice regarding the B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 19 2. 7&8 St Marys Care Home 3. 7 & 14 4. 7 5. 9 6. 16 recording of manual handling risk assessments be reviewed and improved. Care plans should be developed to contain more detail about each individual needs (for example, detailing the things that people can do either for themselves or with support, individual preferences about how people want their care to be delivered) in order to maximise their independence, choice and control. Where a review has identified a change in a service users need or the intervention to be taken by staff, this should result in the interventions section/care plan being updated to reflect this change. It is recommended that the temperature of the treatment room is monitored and any necessary action taken to ensure that the room is maintained at an appropriate temperature for the safe storage of medicines. It is recommended that the complaints policy and procedure is proactively promoted at St Mary’s to ensure that all service users and their relatives feel comfortable about raising concerns. St Marys Care Home B54 S751 St Marys V220136 210405 STAGE 4.doc Version 1.30 Page 20 Commission for Social Care Inspection No 1 Hopetwon Studios Brinkburn Road Darlington DL3 6DS 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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