Inspection on 29/05/07 for St Mary`s Care Home

This inspection was carried out on 29th May 2007.

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 27/06/06

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 Key Unannounced Inspection 29th May 2007 14:30 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.V339842.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.V339842.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) of places St Mary`s Care Home DS0000000751.V339842.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. 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. 27th June 2006 2. 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. Weekly fees charged at the home range from £382.50 to £402.50 St Mary`s Care Home DS0000000751.V339842.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 the 29 May 2007. The home did not know the inspection was going to take place. The plan for the inspection was to talk with the people about living in the home; to meet with nursing and care staff and the home’s management team; and to look at records. Some information we had asked for, about the home had been sent to us, along with some service users surveys. Some of this information has been included within this report. What the service does well: What has improved since the last inspection? The home has continued to offer a very good standard of care and support for the people who live there. The manager and staff are continually working hard and looking to improve the care and support they give to the people who live at the home. Several rooms have been redecorated, new lounge chairs have been purchased and soft furnishings replaced in the main lounge area. St Mary`s Care Home DS0000000751.V339842.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. The summary of this inspection report can be made available in other formats on request. St Mary`s Care Home DS0000000751.V339842.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.V339842.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): 2,3 &6. Quality in this outcome area is good. People can be assured that their needs are appropriately assessed prior to admission to the home and that they are given sufficient information to make an informed choice before moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was seen that service users or their representatives have signed a contract with the home. The contracts were detailed and included a breakdown of the fees and who was responsible for paying them. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 9 The manager confirmed that visits people before their admission to the home takes place. This is to carry out an assessment of the persons needs. Four care plans examined contained notes from assessments made on these visits. Also, each person’s care plans contained assessments from the placing authority that were responsible for commissioning the care at the home. The home does not provide intermediate care. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. Good systems are in place to ensure that health care needs of the people are met. People can be confident that their privacy and dignity is protected and that they are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recording in people’s care plans has improved. The plans gave clear instructions to staff on how to meet people’s diverse needs. The plans are kept under review and monitored by the manager. The care plans indicated that people had access to other health care professionals such as the community psychiatric nurse, opticians and chiropodists. Risk assessments are in place, with documented plans and measures taken to minimise risks to people. Where the risk of a person falling out of bed has been identified, and where bed rails have not been suitable, a low, ‘futon’ style bed has been supplied. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 11 The medication administration records were inspected. They were completed properly. Stock checked against the balance on the medication record was correct. Procedures were in place regarding medication administration; the staff on duty were knowledgeable about these procedures. Staff were observed providing a service to people in a kind and helpful manner. Relation ships between staff and people living at the home were positive and friendly with good natured banter. Staff were seen to be treating people with respect and dignity and this was also reflected within the care plans. People said that the ‘girls are kind’ and ‘the staff always help me, they just seem to know what to do and when’. A relative commented ‘ I feel this is a very well run home my mother is well cared for, she gets the very best care’. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 12 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. The recreational and social needs of people are catered for which enables people to make daily choices and promotes independence. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home employs an activities co-ordinator who produces a varied and interesting activities program, appropriate to people’s needs and interest. The home had a busy and purposeful atmosphere, some people were enjoying chatting with each other, some were listing to music or else joining in with a group activity. Interdenominational services are held in the home enabling people to fulfil any religious needs. People said the food was good, a choice of meals were offered and the menus were well thought out, catering for most people’s tastes. People who required extra food supplements were given high calorie snacks during the day, such as milkshakes and fruit smoothies. One person said ‘I eat very well and have put on weight, the food is very good’ St Mary`s Care Home DS0000000751.V339842.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. People can be confidant that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are adequate written policies and procedures in place to deal with complaints and the 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. People said they would approach the manager or any of the staff team if they had any concerns. 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.V339842.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 Quality in this outcome area is good The home was clean, comfortable and well-maintained providing people with a safe and pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual bedrooms and communal areas were suitably furnished and decorated in a style liked by people living there. Several communal areas have been refurbished and new lounge chairs bought. Some service users bedrooms have been redecorated and new carpet laid. The communal areas of the home were clean and residents confirmed that their bedrooms were also cleaned to a good standard. Disposable gloves and aprons were available for staff use, and staff had been trained in infection control. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 15 There are no outstanding requirements from the fire officer or environmental health officer inspections. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. People can be confident that staff are trained and on duty in sufficient numbers to meet their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence of on going training for staff in such things as moving and handling of service users, fire awareness and prevention of falls, and the protection of vulnerable adults. It would appear, given the high dependency and the frailty of people living at the home, that staff are managing to meet people’s needs. The staffing levels and the deployment of staff must be kept under review in order to maintain this level of care and safety for the people living at the home. People said that staff were always around and answered the call bells quickly. One person said ‘the staff are kind and helpful’ Another service user said ‘ they are really good, they are always willing, I just need to buzz and they come nothing is a problem’. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 Quality in this outcome area is good. People 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. This judgement has been made using available evidence including a visit to this service. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 18 EVIDENCE: The manager of the home is experienced in managing a care service. There was an open, friendly culture between the management team and the staff at the home. Staff said they felt very well supported in their work by the manager. People living at the home and visitors said that the manager was very approachable and they would go to her or any of the staff if they had any concerns. A service satisfaction questionnaire is also used within the home, some of these are sent to service users families and visitors, the results of these are available at the home. The records regarding administration of people’s personal allowances were inspected. All transactions are recorded correctly and receipts are kept. The homes health and safety file was examined; all equipment in the home is regularly checked with valid certificates issued. There are no outstanding issues from environmental health inspections or the fire and rescue services. St Mary`s Care Home DS0000000751.V339842.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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.V339842.R01.S.doc Version 5.2 Page 20 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. 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.V339842.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 DS0000000751.V339842.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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