Inspection on 18/10/05 for St Mary`s House

This inspection was carried out on 18th October 2005.

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 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 House 21/01/09

St Mary`s House 01/02/07

St Mary`s House 01/03/06

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 18th October 2005 11:45 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.V254244.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 House DS0000014243.V254244.R01.S.doc Version 5.0 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 Trustees for the Grace & Compassion Benedictines Sister Kathy Yeeles 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.V254244.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only older people will be accommodated. Residents must be aged sixty five (65) years or over on admission. That no more than twenty eight (28) residents are accommodated. Date of last inspection 9th December 2004 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.V254244.R01.S.doc Version 5.0 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 a Tuesday between 11.45am and 6.30pm. The inspection began with discussions with the Registered Manager (Sister Kathy) and Deputy Manager of the care home in respect of progress made since the last inspection, followed by the examination of four care records. In order to gather evidence on how the home is performing, individual discussions took place with four residents and five care staff. 24 residents were accommodated at the time of the inspection. Other areas and documentation inspected included: the home’s medication systems, complaints and adult protection procedures, staffing levels, recruitment procedures, the provision of activities and staff induction process. What the service does well: What has improved since the last inspection? The home has worked hard to meet the requirements and recommendations of the previous inspection. Much work has been carried out by the Registered Manager and her Deputy in respect of the homes’ pre-admission and care planning procedures. Many aspects in relation to health and safety matters have been addressed. The home has introduced a new induction process for all new staff, which is commendable. St Mary`s House DS0000014243.V254244.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 House DS0000014243.V254244.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 House DS0000014243.V254244.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): 1, 3, and 5. Detailed written information is provided to all prospective residents prior to admission. The home has good systems in place to assess all prospective residents to ensure that no one is admitted to the home, whose needs cannot be met. EVIDENCE: The home has a detailed Statement of Purpose in place designed to help prospective residents choose the right home. It contains details of the home’s aims and objectives, complaints procedure, staffing details, residents’ views of the home and details of how to contact the Commission for Social Care Inspection (CSCI). All residents are also provided with a Service Users’ Guide. This provides details of the accommodation, care planning procedures, meal times, the fee structure, laundry service, the provision for attending healthcare appointments and spiritual care. St Mary’s House currently operates a waiting list as priority is usually given to those who are already in accommodation owned by the Benedictine Sisters. The vast majority of initial enquiries and referrals are made directly to the St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 Page 9 home by telephone, or in some instances people may choose to knock on the door and enquire within. All prospective residents are initially asked to complete an application form prior to a thorough assessment of their needs being carried out by the Registered Manager. A letter of confirmation is then written to each person and or their representative to state whether or not the home can meet the assessed needs. All of the residents spoken with confirmed that they were given the opportunity to visit the home prior to admission and in some cases, choose their own bedroom. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 9. The home has worked hard to ensure that the assessed needs of residents are met by the homes care planning procedures. Adequate systems are in place for the administration of medication. EVIDENCE: Since the last inspection the home has implemented a new care-planning format. All residents now have their own individual plans of care that are devised by the person’s named keyworker in agreement with the individual. All staff have recently received training and guidance from the Deputy Manager regarding the new plans of care. All care plans seen were based on core personal care needs for example: maintaining oral care, dressing and bathing, medication, eating and drinking and mobility. All were found to be personalised to the needs of the individual. Although risk assessments are in place for the prevention of falls and nutrition, they do not currently provide staff with sufficient details regarding the action that is to be taken in order to minimise any potential risks. A requirement has been made in respect of this. All specialist needs are identified within the plans of care and there was evidence that specialist advice is sought as necessary in relation to maintaining St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 Page 11 pressure area care, monitoring psychological health and continence. It was noted within the care plans that care staff are being encouraged to implement a medical approach with regard to relieving pain. This is considered to be outside of the care home’s remit, as the home is only registered to provide residential care. This was discussed in length with the Deputy Manager of the home and a requirement made. The home’s medication systems were viewed and found to be in order. The home uses a monitored dosage system, and currently does not hold any controlled drugs on the premises. Three senior members of staff only are allocated to dispense medicines. Risk assessments are carried out for residents who wish to self-medicate, however they do not currently identify any potential risks or provide an outcome of the assessment i.e. whether or not the person is able to self-medicate. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. This home offers residents a variety of stimulating and meaningful activities. All residents are encouraged to maintain contact with friends/relatives and the local community. EVIDENCE: All of the residents spoken with stated that ‘there is always enough to do’. Many choose to access the local community or nearby park with friends/relatives, whilst others may choose to stay at home. A number of different events have been facilitated by the home in recent months including: painting classes, an ‘all singing and dancing’ show by the care staff, personal fitness groups, piano playing, strawberries and cream during Wimbledon week an open day bazaar and a Tsunami appeal. A resident Chaplain offers Church services and daily mass. All forthcoming activities, events and birthdays are displayed in the dining area of the home. Residents and staff confirmed that visitors are made welcome to the home at anytime. Friends and relatives are often encouraged to stay for a meal in the dining area with residents and staff. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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 and 18. This home has adequate systems in place to ensure that all complaints are dealt with appropriately, however it needs to ensure that up to date written policies and procedures are in place to safeguard residents from harm. EVIDENCE: St Mary’s has a very detailed complaints procedure in place, a simplified version of which is distributed to all residents and is on display in the main entrance area of the home. It was pleasing to note that all of the residents spoken with said that they could not ever imagine having to make a complaint. No complaints have been received by either the home or the CSCI since the last inspection. The home’s adult protection policy and procedure was updated in March 2005. It provides staff with clear guidance and advice regarding PoVA (the protection of vulnerable adults), however it needs to be amended in accordance with local multi-agency guidelines to state that Social Services are now the lead agency. Two senior members of staff have recently received external training in elder abuse. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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, 23 and 25. St Mary’s House provides residents with a warm, comfortable and homely place to live. EVIDENCE: On the day of inspection the home was found to be warm, clean and wellmaintained throughout. A maintenance person is employed by the home to ensure that the building is well looked after. Plumbers and local tradesmen are called to the home as necessary. All residents are provided with their own bedrooms, all of which have en-suite facilities. Residents are encouraged to bring their own personal belongings and furniture with them to the home. A small number of rooms were viewed, which were all found to be personalised to individual preferences and taste. All rooms are centrally heated. All hot water outlets are regulated and pipe work and radiators guarded. This ensures that residents are safeguarded from harm. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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 and 30. Adequate numbers of suitably experienced staff are employed to meet the assessed needs of residents. The arrangements in place for the induction of new staff is commendable. EVIDENCE: St Mary’s House employs a total of 20 care staff, comprising of Sisters and lay staff. 50 of these are trained to at least NVQ level 2 in care. Seven carers are rostered to work in the mornings and five in the afternoon. Two additional staff are always on duty in the kitchen. Residents confirmed that there are always enough staff on duty. Nine new Sisters have recently been recruited from religious communities in India. All of them have had some relevant experience in caring for the elderly, but obviously these would have been very different to that of care in the United Kingdom. The Deputy Manager of the home has recently introduced a new thorough induction programme for the Sisters in order not only to introduce them to the home and working practices, but also a different culture with various beliefs, values and expectations. All of the Sisters are supernumerary for the first six weeks and are under the supervision of a mentor. The induction-training programme is divided into five units comprising of ‘classroom’ and practical learning. They are each provided with a comprehensive portfolio, which covers the following areas: an introduction to the geography of the UK, the home’s mission statement and philosophy of care, adult protection procedures, safe working practices, bathing and St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 Page 16 dressing, death, dying and bereavement and some helpful ‘do’s and don’ts’. The practical sessions include: hand washing techniques, role play and ‘what would you do if’…’ questions. Each of the units is certified and is currently in the process of being evaluated. Three of the Sisters who had recently undertaken this induction were spoken with on the day of the inspection. Their feedback was very positive. This is considered to be commendable and intuitive practice. Recruitment files regarding each of the new Sisters were seen on the day of inspection. All were found to contain photograph identification, written references, certificates, health checks, Visa and a current police check from India. Criminal Record Bureau checks and PoVA First are in progress. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 38. St Mary’s House has good management and administration systems in place. EVIDENCE: The Registered Manager of St Mary’s House is a Registered Nurse by background who has many years experience of caring for older people. Recent study days include: medication, elder abuse, moving and handling, Care Standards and fire safety. She is supported in her role by a Deputy Manager, who has recently completed her Registered Managers Award and is an NVQ assessor. All of the residents and staff spoken with confirmed that the home is well run in the best interests of the residents. This was evident on the day of the inspection. 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 St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 Page 18 senior carers who is due to commence a health and safety course is responsible for updating environmental risk assessments, checking and recording water temperatures and ensuring that all unused taps and showers are flushed through regularly. It was noted during the inspection that a small number of bedroom doors were not fitted with automatic door releases. This was discussed with the Registered Manager and a requirement made. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X 3 X 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X 2 St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 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. 1. Standard OP3 Regulation 14(1)(c) Requirement It is required that details of those present at the time of assessment are recorded on the pre-admission assessment form. It is required 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. It is required that the nutritional risk assessments provide staff with the action that is to be followed to maintain nutrition. It is required that care staff do not assess or carry out duties that are outside of their remit in relation to relieving pain. It is required that risk assessments for those residents who wish to self-medicate, identify the potential risks and provide an overall outcome. This must be recorded on the MAR sheets. It is required that the adult protection procedure is amended in accordance with local multiDS0000014243.V254244.R01.S.doc Timescale for action 18/10/05 2. OP7 13(4)(b) (c) 18/12/05 3. OP7 13(4)(b) (c) 12(1)(a) (b) 12(4)(c) 18/12/05 4. OP8 18/10/05 5. OP9 18/10/05 6. OP18 12(1)(a) 13(6) 18/12/05 St Mary`s House Version 5.0 Page 21 7. OP38 23(4)(a) 12(1)(a) agency guidelines. This must state that Social Services are now the lead agency and provide contact details. It is required that the outstanding fire doors are fitted with automatic door closures. 18/01/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is recommended that a copy of the needs assessment be provided to all prospective residents in order to demonstrate how the home intends to meet their needs. St Mary`s House DS0000014243.V254244.R01.S.doc Version 5.0 Page 22 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.V254244.R01.S.doc Version 5.0 Page 23 - 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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