Inspection on 27/06/06 for St Mary`s Care Home

This inspection was carried out on 27th June 2006.

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 07/12/05

St Mary`s Care Home 21/04/05

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 Mary`s Care Home Church Chare Chester Le Street Durham DH3 3PZ Lead Inspector Bridgit Stockton Unannounced Inspection 11:30 27th June 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 DS0000000751.V295101.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 DS0000000751.V295101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Care Home Address Church Chare Chester Le Street Durham DH3 3PZ 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 3890566 0191 3882806 smnh@btconnect.com Carewell Healthcare Limited Mrs Maureen Priscilla Garrett Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54), Physical disability (2), Terminally ill (3) of places St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Convalescence. Persons over the age of 55 requiring convalescent care may be accommodated commensurate with the home’s statement of purpose and function. 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 function and where appropriately qualified and competent staff are provided. Physical Disability. Up to 2 persons with a physical disability, over the age of 55, may be accommodated commensurate with the home`s statement of purpose and function. 7th December 2005 2. 3. Date of last inspection Brief Description of the Service: St Marys 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 fourteen 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 Marys has close links with four local GP practices, enabling residents to keep their own GP where possible. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of 5 hours on 27th June 2006. The plan for the inspection was to check whether the home had met previous requirements and recommendations; to talk with service users about living in the home; to meet with care staff and the home’s management team; and to look at records. What the service does well: What has improved since the last inspection? Since the last inspection, some policies and procedures have been reviewed in order that service users are properly protected from abuse and staff are now properly checked before starting work at the home. A bedroom has been converted into a storeroom that has freed up some communal space for service users to use. The laundry floor has been replaced, and several bedrooms have been redecorated, along with some communal areas St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 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`s Care Home DS0000000751.V295101.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 DS0000000751.V295101.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be assured that their needs are appropriately assessed prior to admission to the home. EVIDENCE: The manager confirmed that she always visits prospective service users before their admission to the home, to carry out an assessment of needs. Four service users files inspected had pre admission assessments and care management assessments so that a decision could be made about whether the home was able to meet the needs of the individual. Intermediate care is not offered at St Mary’s Care Home therefore this standard was not assessed. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place to ensure that health care needs of the service users are met. Service users can be confident that their privacy and dignity is protected and that they are treated with respect. EVIDENCE: A service user plan has been developed for each service user that identifies needs associated with health and personal care. This ensures that staff are clear about what is required of them in meeting residents needs. The care plans of four residents were inspected they were comprehensive and well written. Careful and thoughtful strategies to address particular needs or problems of some service users were well documented and sensitively written. Risk assessments on the use of bed rails, moving and handling of service users had been reviewed at least monthly. There was evidence of involvement of specialist healthcare people such as the community psychiatric nurse, the dietician and continence nurse. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 10 The residents spoken to felt that the staff “are wonderful” and that their particular needs and wishes were addressed in a kind and professional manner. Residents confirmed that their privacy is maintained and respected by staff. One visitor to the home said ‘staff are tremendous; people are really well cared for. I am delight with the care my husband gets here’ Another resident said ‘the girls really look after us, they seem to know just what I am wanting’ St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 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 the following standard(s): 12.13.14. &15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The recreational and social needs of service users are well catered for, which enables service users to make daily choices and promotes independence. EVIDENCE: There was good practice relating to the promotion of independence and service user choice. The home had lots of visitors coming to the home during the inspection. Staff were friendly and welcoming. An activities organiser is employed at the home and there was a varied range of activities offered. Residents said they ‘looked forward to going out on trips in the minibus’. On the day of the inspection some service users had just returned from a trip to a nearby reservoir, they had really enjoyed this. One resident said ‘ we watched some wildlife and had coffee, it was just the right length of time, we are back in time for lunch’. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 12 One resident said ‘ we have a party organised to celebrate anything, it is one ladies special birthday coming up, I am sure we will be having a party, we all get a birthday cake’. All of the service users said the food was good, a choice of meals were offered and the menus were well thought out, catering for most peoples tastes. Two visitors to the home were also taking lunch with the service user they were visiting. One visitor said ‘ I always get asked if I want to stay for a meal, it is always lovely, the staff cannot do enough for people’. Residents who required extra food supplements were given high calorie snacks during the day, one service user was being offered chocolate cake with double cream, another was enjoying a milkshake. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 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 the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confidant that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse. EVIDENCE: There are adequate written policies and procedures in place to deal with complaints and the care staff spoken to confirm they were aware of these. Staff knowledge of these help ensure that they were able to address any issues or anxieties of the residents, relatives and visitors to the home. Staff training has taken place in the protection of vulnerable adults in abuse. Staff recruitment procedures were adequate and staff were employed and deployed following appropriate CRB and POVA checks. The manager and staff team were clear and confident in the protection of vulnerable adult procedures. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 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 the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, comfortable and well-maintained providing service users with a safe and pleasant environment. EVIDENCE: Individual bedrooms and communal areas were suitably furnished and decorated in a style liked by people living there. Residents spoken to said they liked being able to bring into the home small items of furniture along with pictures and photographs to make there own rooms more pleasant and feel more like home. The communal areas of the home were clean and residents confirmed that their bedrooms were also cleaned to a good standard. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment and training of staff is good which contributes to the ongoing safety of service users. EVIDENCE: The home had staff files in place that provided evidence that the appointment of a new staff member is made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. There is a commitment at the home to having a trained workforce with 15 out of the 29 care staff having completed NVQ level two or three training in care. Staff said they found the training helpful in improving their day-to-day practice. All new staff receive a thorough induction and this was documented in the staff files examined. St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home is well managed. Systems and safeguards are in place to ensure the health, safety and welfare of service users and staff is protected. EVIDENCE: The manager of the home is very experienced in managing a care service. There was an open, friendly culture between the management team and the staff at the home, and staff said they felt very well supported in their work. There was evidence is staff files that regular supervision of staff takes place and that staff are appraised. Service users said that the manager was very approachable and they would go to her if they had any concerns. Some service users personal allowances are held at the home. Financial policy and St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 17 procedures are in place to ensure that all transactions can be accounted for. Receipts are retained and signatures obtained for any financial transaction regarding service users money. The homes health and safety files was examined; all equipment in the home is regularly checked with valid certificates issued St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown 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. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Care Home DS0000000751.V295101.R01.S.doc Version 5.2 Page 21 - 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!