Inspection on 07/12/05 for St Mary`s Care Home

This inspection was carried out on 7th December 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 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 Rachel Dean Unannounced Inspection 7th December 2005 09:30 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.V257571.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 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.V257571.R01.S.doc Version 5.0 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. 14th & 21st April 2005 2. 3. Date of last inspection 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. 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-leStreet, close to the local high street with its shops and amenities. St Mary’s has close links with four local GP practices. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 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 one day. This inspection looked at a number of important areas, such as the building and physical surroundings that the residents live in, whether or not the home is kept clean, the staffing and training provided, how the home is managed, how the manager and owners make sure that they are providing a good service, arrangements for helping people with their personal finances and how the people living, visiting and working in the home are kept safe. During this inspection interviews were held with four service users, two relatives, two members of staff and the manager of the home. Twenty four service users and fourteen relatives returned comment cards about their experiences of living and visiting St Mary’s. A tour was made of the premises and observations were made throughout the day of the inspection. In addition to this a selection of the records kept by the home were inspected. What the service does well: What has improved since the last inspection? Since the last inspection an air conditioning unit has been installed in the treatment room. This has helped keep it cool and make sure that medication is stored at a safe temperature. The re-decoration of the home has continued and a big improvement has been seen in the standard of decor in the last year. This has improved the home’s physical environment and made the home a more comfortable place to live, with individual rooms being decorated in a more individual and homely way than before. Comments made about the home included, ‘it’s kept clean and treated like a home, not a show house, I like the way it’s a homely environment’. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These key standards were not fully assessed during this inspection. They were inspected during the previous inspection. EVIDENCE: St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These key standards were not fully assessed during this inspection. They were inspected during the previous inspection. EVIDENCE: St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These key standards were not fully assessed during this inspection. They were inspected during the previous inspection. EVIDENCE: St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 11 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): These key standards were not fully assessed during this inspection. They were inspected during the previous inspection. EVIDENCE: It is required that the procedures for referring an individual to the POVA list are written up and added to the home’s existing adult protection and disciplinary policies and procedures (This is outstanding from the previous inspection and the previous timescale of 30th may 2005 has not been met). At the time of this inspection the information was available in the home and had been used, but had not been formally incorporated into the home’s existing policies and procedures. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 12 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 The home provides service users with a comfortable environment to live in, although lack of storage space makes some areas appear cluttered and means that some items have to be stored inappropriately in people’s rooms. The home employs appropriate domestic staff and is kept clean. However, some facilities in the laundry need to be improved to increase hygiene and safety. EVIDENCE: During this inspection the inspector looked around the building and talked to staff and service users about the home. 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. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 13 On the day of the inspection the home was found to be clean. The people who were consulted during the inspection indicated that the home was usually kept clean and that there were enough domestic staff employed to manage this. Comments made included, ‘it’s kept clean and treated like a home, not a show house, I like the way it’s a homely environment’. Observations showed that service users had brought their own possessions in to the home and had personalised their rooms where they wanted to. A few areas were found that still needed attention. The laundry floor covering had holes in it and needs to be replaced with an impermeable and safe floor covering. The laundry was also very cold on the day of inspection, with only a small, freestanding, electric heater being available. This is inappropriate for the size of the building and is a fire risk in an area where a large amount of laundry is handled, dried and stored. Some pieces of furniture in the home, particularly the furniture in the outside smoking area and the office chair in the upstairs lounge would benefit from replacement. It is also required that advice is sought from the Fire Authority regarding the home’s current practice of propping a large number of doors open with wooden chocks or furniture. Where necessary appropriate door closure systems should be fitted that allow doors to be propped open and keep service users safe in the event of a fire. There is still not enough storage space in the home, with no action having been taken to address this since the last inspection. Spare equipment was still being stored in lounge areas, bathrooms and corridors. This situation is limiting service users and staff’s access to the home’s communal space and facilities. In addition to this, some specialist feeds and equipment were being stored in the rooms of service users because there was nowhere else to store it. This is inappropriate as it limits the space available in people’s rooms and does not protect their privacy, with some of the items being clearly visible to anyone passing in the corridors. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Overall the home provides appropriate levels of staffing. However, staffing levels do fluctuate and would benefit from consistently being maintained at the higher levels. Service users and relatives felt that the staff employed by the home were pleasant, caring and friendly. Recruitment practices include checks to make sure that new staff are suitable to work with vulnerable adults. However, the manager needs to make sure that two written references and an explanation of any gaps in employment history are obtained for all staff before they start work. Staff training is given high priority at the home, with staff attending regular training in relevant areas. EVIDENCE: Overall people were very complimentary about the care provided at St Mary’s and the staff who worked there. Examples of some of the comments made by people are, ‘my mothers needs are catered for with a very high standard of care. Staff are all very pleasant and friendly and nothing is to much trouble to them’ and ‘I am perfectly happy with the care mother receives....staff are friendly and helpful, extremely dedicated in their jobs’. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 15 However, during this inspection some negative comments were also made by service users and relatives. These comments focused on weekend staffing levels and the time people sometimes had to wait before help was available to take them to the toilet. For example, ‘I most times have to wait a long time to go to the toilet....I find it distressing’, ‘could have more toilet care’ and ‘you are short on weekends’. Staff rotas were inspected and showed that daytime staffing levels were usually between seven and ten care staff, plus nursing staff. However, sometimes only six care staff, plus nursing staff were on duty. This is quite a big variation between the highest and lowest staffing levels. Staff spoken to during the inspection did not think that staffing levels were a problem. Discussions with the manager indicated that she was aware that people sometimes had to wait for assistance if staff were busy, but that she was not aware of people having to wait for unreasonable lengths of time. It is recommended that the fluctuations in staffing levels are reduced to ensure that staffing levels are always at an appropriate level to minimise the chances of people having to wait for assistance. The recruitment records of three recently employed staff were inspected. Records of Criminal Record Bureau checks were available for all staff working in the home. However, the home was also storing all of the original criminal records bureau disclosure forms, regardless of how old they were. Due to the sensitive information contained on these forms they should only be kept for a limited period and then destroyed. Guidance on this is available from the Criminal Records Bureau. The records inspected showed that the majority of staff went through the required recruitment checks. However, one staff member only had one written reference on file and some examples were found where there was no record of employment gaps having been discussed with the applicant. Training continues to be given a high priority at St Mary’s with staff being complimentary about the support and training available to them. For example, ‘the training is good, I’ve done lots of training here’ and ‘you can ask for training and she (the manager) will try and accommodate’. A lot of National Vocational Qualification (NVQ) training has been provided this year, with Fifteen out of twenty-six staff having completed NVQ’s. The manager is in the process of finding funding so that the remaining staff can complete NVQ training. Training in other areas, such as manual handling, equality and diversity, focus on food and fire awareness has also been provided. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The home is managed by an experienced and appropriately qualified manager, who is registered with the CSCI. The manager is considered to be approachable and actively seeks the views of service users, relatives and professionals about the home. Appropriate systems are in place to help service users manage small amounts of personal money in a safe and secure way. Regular checks and maintenance contracts are in place to help make sure that staff and service users are kept safe. However, the use of small portable heaters in the laundry, frequency of fire drills and the propping open of fire doors needs to be reviewed. EVIDENCE: St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 17 St Mary’s continues to be managed by an appropriately experienced and qualified person. Staff, service users and relatives commented on the manager being approachable, supportive and friendly. For example, ‘the manager’s door is always open if you have any problems’ and ‘you can get or ask for help from anyone without feeling belittled, it’s supportive’. The manager had recently carried out a survey for residents, relatives and professionals visiting the home and was aware of the issues that people felt could be improved in the home. This included the comments discussed previously about weekend staffing levels and waiting for assistance to use the toilet. The homes owners carry out regular visits to the home to monitor its performance. This includes writing a monthly report on their findings. However, inspection of these reports and discussions with the manager indicated that there has recently been a three month gap in these visit reports. Appropriate arrangements were found to be in place to help service users manage small amounts of personal money. The storage arrangements for this money and the financial records of three service users were checked and found to be accurate and appropriate. The maintenance arrangements and records for the maintenance of the homes equipment were inspected. Regular tests are carried out to ensure that hot water is maintained at safe temperatures and that fire alarms and equipment are working correctly. Suitable maintenance contracts are in place for the servicing and maintenance of lifting equipment, heating and electrical equipment. Staff training is provided in key areas, such as moving and handling, fire safety and first aid. However, although fire drills took place regularly and were recorded, these drills did not occur frequently enough to ensure that all day staff received a drill twice each year and that all night staff received a drill three times each year. The records of the drills also need to include the time that the drill took place. The use of the portable heaters in the laundry and the propping open of fire doors (previously discussed under ‘Environment’) also need to be reviewed in the interests of health and safety. St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 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. 1 Standard OP18 Regulation 13(6) Timescale for action It is required that the procedures 28/02/06 for referring an individual to the POVA list are written up and added to the home’s existing adult protection and disciplinary policies and procedures (This is outstanding from the previous inspection – timescale of 30th may 2005 not met). 30/05/06 It is required that storage provision in St Marys be reviewed and additional storage space provided so that equipment is not stored in communal areas or inappropriately in people’s rooms (This is outstanding from the previous inspection – timescale of 31st August 2005 not met). 28/02/06 It is required that advice is sought from the Fire Authority regarding the home’s current practice of propping a large number of doors open with wooden chocks or furniture. Where necessary appropriate door closure systems should be fitted that allow doors to be propped open and keep service users safe in the event of a fire. DS0000000751.V257571.R01.S.doc Version 5.0 Page 20 Requirement 2 OP19 23(2)(l) 2 OP19 & OP38 23(4) St Mary`s Care Home 4 OP26 5 OP26&OP3 8 6 7 OP29 OP33 The current laundry floor covering has holes in it and needs to be replaced with an impermeable and safe floor covering. 13(4)(c) & The use of small portable electric 23(4) heaters in the laundry must be reviewed and a safe and adequate heating source provided. 19(4) & Two written references must be Schedule obtained for all new staff before 2 they start work in the home. 26 Regulation 26 reports must be completed on a monthly basis. 13(3) & 13(4)(c) 31/03/06 28/02/06 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP27 Good Practice Recommendations Some pieces of furniture in the home, particularly the furniture in the smoking area and the office chair in the upstairs lounge would benefit from replacement. It is recommended that the fluctuations in staffing levels are reduced to ensure that staffing levels are always at an appropriate level to minimise the chances of people having to wait for assistance. Any gaps in employment history should be discussed with the applicant and recorded during their interview. Criminal Record Bureau disclosures should only be kept for a limited time and then destroyed. This must be done in accordance with the guidance available from the Criminal Record Bureau. All day staff should take part in a fire drill twice each year and all night staff should take part in a fire drill three times each year. The records of fire drills should include the time that the drill took place. 3 4 OP29 OP29 5 OP38 St Mary`s Care Home DS0000000751.V257571.R01.S.doc Version 5.0 Page 21 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.V257571.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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