Inspection on 01/03/06 for St Mary`s House

This inspection was carried out on 1st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Mary`s House 21/01/09

St Mary`s House 01/02/07

St Mary`s House 18/10/05

St Mary`s House 09/12/04

St Mary`s House 29/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Mary`s House 38/39 Preston Park Avenue Brighton East Sussex BN1 6HG Lead Inspector Niki Palmer Unannounced Inspection 1st March 2006 10:15 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 House DS0000014243.V284749.R01.S.doc Version 5.1 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 House DS0000014243.V284749.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s House Address 38/39 Preston Park Avenue Brighton East Sussex BN1 6HG 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) 01273 556035 mailus@stmaryshouse.fsnet.co.uk The Grace and Compassion Benedictines Vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be older people aged sixty five (65) years or over on admission. That no more than twenty eight (28) service users are accommodated. Date of last inspection 18th October 2005 Brief Description of the Service: St Mary’s House is a residential home registered to provide care and accommodation for up to twenty-eight older people. The home is owned and run by the Benedictine Sisters of our lady of Grace and Compassion, a registered charity since 1954. The Charity is the registered owner of a further four residential homes, a nursing unit and several sheltered housing schemes. The home is comprised of two detached properties, which have been extended for its current use. It is situated within walking distance of local shops and bus routes into Brighton and overlooks Preston Park. The home is presented across three floors with a shaft lift providing level access to all floors. Residents’ accommodation consists of twenty-eight single rooms all with en-suite facilities. Shared facilities include a large lounge, dining room, hairdressing room, chapel and a large enclosed rear garden. The homes literature states that one of its main aims is to provide care within the home, which is unique personal and special. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at St Mary’s House will be referred to as ‘residents’. This unannounced inspection took place on Wednesday 01st March 2006 between 10.15am and 4.00pm. The inspection began with discussions with the acting Manager of the home in respect of progress made since the last inspection. In order to gather evidence on how the home is performing, individual discussions took place with approximately eight residents whilst others commented on their care during the lunchtime period, the Inspector having been invited to join them for a meal. In addition four care staff and a housekeeper were spoken with. 24 residents were accommodated at the time of the inspection. Other records and documentation inspected included: three individual plans of care, the systems in place to safeguard residents from harm and abuse, staffing rotas, a sample of the home’s health and safety checks, quality assurance systems and the home’s procedures for handling residents’ monies. An inspection of the premises also took place. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 18th October 2005. What the service does well: What has improved since the last inspection? Since the last inspection a detailed audit of falls has been completed and the home’s nutritional screening assessment has been amended with support and advice from a Community dietician. The home’s adult protection procedure St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 6 has been amended in accordance with local multi-agency guidelines in order to help safeguard residents from potential harm, abuse and neglect. Automatic fire door closures have been fitted to outstanding fire doors and some areas of the home have been redecorated. 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 House DS0000014243.V284749.R01.S.doc Version 5.1 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 House DS0000014243.V284749.R01.S.doc Version 5.1 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): 2 and 3. All residents have a statement of terms and conditions of contract. EVIDENCE: Residents are provided with a copy of the home’s terms and conditions of contract either on, or shortly after admission. Copies of these are kept within individual care records. Those seen provided detailed information relating to the room which is to be occupied, the overall care and services, the fees payable and by whom and any additional services and costs. As there have been no new admissions since the home’s last inspection, it was not possible to thoroughly assess the home’s pre-admission procedures on this occasion, although detailed discussions took place with the acting Manager of the home in respect of a requirement made in the last report - that details of those present at the time of assessment are recorded on the pre-admission assessment form. This will be followed up at subsequent inspections. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 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 and 10. The current care planning systems in place do not ensure that all health and personal care needs of residents are identified, met and any risks reduced. These shortfalls have the potential to place residents at risk. EVIDENCE: Four individual plans of care were inspected. Whilst on the whole they were found to provide care staff with sufficient information to meet the assessed needs of residents, not all of them were up to date and accurate. For example four residents had recently been unwell, yet their care plans had not been updated to state what action needed to be taken by staff in order to support individuals during their illness. It was a requirement of the previous inspection report for the home to ensure that falls risk assessments are in place for all residents who are at risk of falling. Since the last inspection the Deputy Manager of the home has undertaken a detailed audit of falls within the home between March 2004 and September 2005 as a baseline prior to the introduction of a falls risk assessment. This proved to be very informative. It identified that the majority of falls occur in residents’ own bedrooms at certain times during the day, St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 10 usually at a time when staffing numbers are reduced – as a result of the Sisters attending their religious duties in the chapel. Despite the Inspector being informed that care staff have undertaken environmental assessments of individuals’ bedrooms since this time, there were no records available for inspection. The home is required to ensure that written environmental and room risk assessments are in place to identify any potential risks and reduce the risk of falls. Since the last inspection the home has amended it’s nutritional screening assessment with support and advice from a Community Dietician. Whilst those seen were found to be sufficiently detailed with information such as individual’s weight and body mass index, the home needs to include practical advice for staff; for example what the person’s preferences and likes and dislikes are and what types of food are considered to be low in sugar and considered suitable for a diabetic controlled diet. Although a detailed inspection of the home’s medication systems was not carried out on this occasion, it was pleasing to note that good risk assessments are now in place for all residents who wish to self-medicate. One signed by the member of staff completing the assessment and the individual themselves they are kept within personalised care plans. All residents and observations of staff’s interactions with others confirmed that that staff uphold the privacy and dignity of residents. All residents are addressed by their preferred term and are spoken with in a manner that is appropriate, kind and respectful. Two of the residents spoken with said that staff always knock on bedroom and bathroom doors before entering and said that they always have and continue to feel ‘valued’. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 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): 13, 14 and 15. Residents are encouraged to remain in close contact with friends and relatives and are supported to make decisions and choices in most areas of their lives. The arrangements in place for the provision of food are good. EVIDENCE: All residents spoken with confirmed that relatives and friends are always made to feel welcome to the home. They are always offered a warm drink and lunch as necessary. Residents also said that they are encouraged by the home to exercise choice and control over their lives as much as possible. The vast majority of residents spoken with said that they view St Mary’s House as their home and can come and go as they wish, get up and go to bed whenever they choose and participate in a variety of activities - or not. The Inspector enjoyed a vegetarian option on the day of inspection. It was found to be tasty, hot and nutritious. The dining area is pleasantly decorated, which encourages residents to use it on a daily basis for each meal. All residents spoken with said that since a new chef has been employed the standard of food has improved. Their comments included: ‘it’s very good’, ‘we never go hungry’ and ‘the staff are always willing to find you an alternative if you don’t like what’s on offer’. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 12 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): 18. The home has adequate procedures in place to ensure that residents are protected from harm, neglect and abuse. EVIDENCE: The home has a detailed adult protection policy and procedure in place, which has been amended in accordance with local multi-agency guidelines. It provides staff with clear guidance and advice regarding PoVA (the protection of vulnerable adults). Staff spoken with appeared to have a good understanding of what constitutes abuse and the actions that they would take in the event of suspecting abuse. No adult protection alerts have been raised since the last inspection. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 13 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, 20, 21 and 26. Whilst St Mary’s is generally in good decorative order and provides residents with a homely and comfortable place to live, the health, safety and welfare of residents, staff and visitors is not promoted. EVIDENCE: An inspection of the premises showed that the home is generally wellmaintained, clean and tidy throughout. All toilets and bathrooms are pleasantly decorated and deliver hot water at the recommended 43oC. All residents spoken with said that they are always offered the choice of either having a bath or shower at times to suit them. On the day of inspection the laundry room was in the process of being repainted, following the installation of a new washing machine the week prior to the inspection. Residents confirmed that their laundry is always well cared for, washed and ironed. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 14 Although suitable equipment is provided in individual bedrooms and bathrooms throughout the home to meet the personal care needs of residents (gloves and aprons etc), it was concerning to note that the Inspector was not informed about a small number of residents who had been unwell with vomiting and diarrhoea a few days prior to the inspection. Consequently some rooms were viewed and residents spoken with who were unwell. The home must ensure that the risks of cross infection between residents, visitors and staff is minimised. It was pleasing to note that since the last inspection report all fire doors throughout the home have been fitted with automatic door release closures on activation of the fire alarm. It was found however, that not all doors closed properly on release, whilst one was being wedged open, as the batteries were in need of replacing. An inspection of the homes most recent fire service report, which was carried out in January 2006 had also identified these concerns amongst some others that were still outstanding from the previous inspection in January 2005. These must be prioritised and acted upon to ensure the health and safety of residents and staff within the home. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 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. Residents’ needs are mostly met by kind, caring and professional staff, however insufficient numbers of staff are on duty at certain times throughout the day to meet the assessed needs of residents. EVIDENCE: All of the residents spoken with spoke very highly of the staff working at St Mary’s House. Their comments included ‘they’re wonderful and kind’, ‘very hardworking’ and ‘have a great sense of humour’. Throughout the duration of the inspection it was pleasing to observe positive interactions between all staff and residents. As already mentioned under Standard 8, concerns have been raised in respect of staffing levels being inadequate at certain times during the day. Whilst the staffing rota indicates that there are normally seven carers rostered to work in the mornings and five in the afternoon, through discussions with staff and residents it emerges that there are particular times during the day whereby the Sisters attend their religious duties and are therefore not at hand to attend to the needs of residents. The home is required to review the current staffing levels based on a needs assessment of the residents accommodated and ensure that the staffing rota reflects the actual numbers of staff on duty at all times. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 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 and 38. St Mary’s House is generally a well managed home that is run in the best interests of residents. EVIDENCE: The acting Manager has been in post since December 2005. She is very experienced with over 17 years of working with older people. Prior to this post she was the Registered Manager of a sister home for five years. She has obtained her Registered Managers Award and attended the following relevant courses to her work: personal care, death and dying, medication, assessment, admissions and care planning, activities and social care, recruitment and selection and induction and supervision of staff. Throughout the inspection she demonstrated a clear understanding of the needs of the residents living at St Mary’s House and observations and discussions with staff and residents confirmed that she is respected, approachable and provides clear leadership throughout the home. Her application to become the Registered Manager of St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 17 the home is being processed by the Commission for Social Care Inspection (CSCI). Residents’, relatives and friends and professional satisfaction questionnaires were given out by the home in August 2005. The results of each questionnaire have been published and made available for residents and visitors to the home to see in an easy to read and understand format. All responses were very positive and indicate that the home is well managed, organised and strives to improve residents’ quality of care by obtaining feedback from others. Most residents and/or their relatives manage their own finances with the exception of one individual. Whilst records are maintained of each transaction the home is required to ensure that all entries are clear, legible and countersigned. For Standard 38, please also refer to Standards 19 and 26. A sample of the home’s health and safety records were examined. Electrical PAT testing is carried out annually for all appliances in the home. Emergency lighting is tested on a quarterly basis and fire alarms, weekly. One of the senior carers has undertaken a Health and Safety course, which has been very detailed in relation to the law, legislation and environmental risk assessments within a care home setting. She commented that she has found the course to be very useful and now feels more confident in her daily work. St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 3 3 X X X X 2 STAFFING Standard No Score 27 1 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 1 St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes. 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 OP7 Regulatio n 15(1)(2) (b)(c) 13(4)(b) (c) Requirement That care plans are updated on a regular basis to enable staff to meet the assessed needs of residents. That falls risk assessments are completed in accordance with guidelines produced by the Department of Health (NICE). These must give clear written guidance for staff to follow to prevent the risk of falls [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION]. That nutritional risk assessments provide staff with the action that is to be followed to maintain nutrition [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION]. That automatic door closures are checked regularly and batteries replaced. That fire doors are not wedged open at any time [IMMEDIATE REQUIREMENT]. That all fire doors close securely when door guards are released. That all recommendations made DS0000014243.V284749.R01.S.doc Timescale for action 01/03/06 2. OP8 30/04/06 3. OP8 13(4)(b) (c) 30/04/06 4. 5. 6. 7. OP19& OP38 OP19& OP38 OP19& OP38 OP19& 23(4) 23(4) 23(4) 23(4) 01/03/06 01/03/06 01/03/06 30/04/06 Page 20 St Mary`s House Version 5.1 OP38 8. OP26 13(3) & 16(2)(j) 9. OP27 18(1)(a) 17(2)& Sch4 17 & Sch 4 (9)(a) 10. OP35 by the Fire Safety Officer are prioritised and acted upon. That good procedures are in place and followed to minimise the risks of cross infection between residents, staff and visitors. That staffing levels are reviewed based on a needs assessment of the residents accommodated. Staffing rotas must reflect the actual numbers of staff on duty. That all records for handling residents’ monies are clear, legible and countersigned. 01/03/06 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Mary`s House DS0000014243.V284749.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 House DS0000014243.V284749.R01.S.doc Version 5.1 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. 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!