Inspection on 21/06/05 for St Mary`s House

This inspection was carried out on 21st June 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 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 22/08/06

St Mary`s House 22/11/05

St Mary`s House 29/11/04

St Mary`s House 10/06/04

St Mary`s House 08/12/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE St Marys House 71 Ormond Avenue Hampton Midlesex TW12 2RT Lead Inspector Sharon Newman Unannounced 21 June 2005 11:00 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 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 Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Marys House Address 71 Ormond Avenue Hampton Middlesex TW12 2RT 020 8979 2847 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sylvia Warren Mrs Sylvia Warren Care Home only (PC) 24 Category(ies) of Old age not falling within anyothe category (OP) registration, with number Sensory impairement (SI) of places St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2004 Brief Description of the Service: St Marys House is registered to provide accommodation for 24 older persons. The home is owned and managed by Mrs. S Warren who takes a pro-active dedicated and hands-on approach to care. Many of the staff have worked at the home for a number of years. The home is situated in an affluent residential road which is tree-lined and attractive. The building is a substantial (extended), detached property with a well-kept garden. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 21st June 2005. The Registered Manager was present throughout the inspection and one staff member was also spoken to. Records examined included care planning documentation, health and safety information, medication records and staff files. A tour was also taken of the premises. Staff were welcoming and open throughout the inspection visit. Interaction observed between staff and service users demonstrated a caring attitude by staff members. The Manager was very helpful and gave the impression of a genuine commitment to her work and to the residents. Residents spoken to were also helpful and very open and forthcoming with the information they provided about the home. Feedback from the residents was overwhelmingly positive, one resident commented that the food was ‘lovely’ and was ‘home cooked’. Another said ‘I don’t think anywhere else could possibly be any better’. Another resident reported that ‘It is like a first class hotel here’ and ‘I am very well looked after.’ One resident said that ‘you will go a long way before you find a better home’. What the service does well: Staff have a good rapport with residents and there is a strong emphasis on the importance of respecting residents dignity, choice and privacy at this home. The home provides wholesome nutritious meals and residents are offered a choice of menu. The home provides a good range of activities for residents and also ensures their healthcare needs are met. There is a good standard of cleanliness at this home and the Manager takes pride in ensuring these standards are maintained. The Manager said she allows staff to work flexibly and this ensures staff are happier in their roles and enables them to better meet the needs of the residents. She runs the home efficiently and puts the needs of the residents first. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4, 5 Good information is provided about the home to residents to enable them to make decisions about their care. There is a strong emphasis on meeting the resident’s needs at this home to ensure they are comfortable and happy. Residents are regarded as individuals and treated with respect. EVIDENCE: A Statement of Purpose is in place and contains information about: the staff and the organisational structure, assessment visits by the Manager, activities available and complaints. The Residents Guide is comprehensive, informative and detailed. It contains information including: terms and conditions, resident’s rights, the complaints procedure, meals and activities. The home has a care philosophy which contains the statement that the home offers ‘at all times, sensitive and conscientious care from competent and committed well trained staff who understand the needs of elderly people’. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 9 During conversations with the Manager she stressed the importance of respecting the residents privacy and dignity and providing a comfortable homely environment. Full assessments and contracts were seen to be in place for two residents whose files were seen on the day of inspection. Two prospective residents were being shown around on the day of inspection. The Manager and staff were observed to spend time talking to them and their families and demonstrating empathy and sensitivity. The Manager said she carries out the assessment of all residents and that all prospective residents are invited to come to the home - if they can do so – to have a look around and chat to the staff. She reported that residents could stay for a trial period or visit for a day and have lunch at the home. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Good consultation with residents takes place allowing them to make decisions about their lives. Personal and healthcare needs are met. Medication is stored administered and recorded appropriately. The home has access to a pharmacist for advice. EVIDENCE: Two residents files were examined and found to be well organised, concise and easy to follow. The inspector found that most of the documentation is being regularly updated, however, one risk assessment had not been updated since 25/06/04 and one recently admitted resident did not have a complete care plan or risk assessments in place. Information in the care plans is gathered in a systematic way using a model of care based around the resident’s activities of daily living. Information was seen to include resident’s likes and dislikes and interests. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 11 Evidence was seen in care plans of input from health care professionals including: occupational therapists, GP’s, community nurses and social workers. District Nursing input is provided regularly to the home and the GP visits weekly. This was confirmed by a resident who said ‘the doctor comes on a Friday morning.’ The Manager said that if the home staff have any concerns regarding the health of a resident they will refer to the appropriate health care professional. An NHS chiropodist visits regularly and residents may choose to contact a private chiropodist if they wish. There is a room at the home where residents may go to be seen in private by a visiting health care professional or the hairdresser. Medication was stored securely within a locked cupboard on the day of inspection. The Manager said the home has a good relationship with a local chemist. Medication was observed to be stored in a monitored dosage system and all medication administration records were fully completed. There are comprehensive medication policies in place at the home, including one for homely remedies, disposal of medicines and a self-medication policy. The Manager reported that a pharmacist carries out a medication audit at six month intervals. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 Residents are able to exercise choice and control over their lives and family and friends are encouraged to visit. A choice of meal is offered to residents and they enjoy a wholesome balanced diet in pleasant surroundings. EVIDENCE: Some residents were seen to be sitting in one of the two lounges talking to each other, reading newspapers and books or resting. Residents informed the inspector that they could choose to go to their rooms whenever they wish. Throughout the inspection, residents were observed to be reading newspapers, knitting or resting in their own rooms. One resident commented that they like to listen to music in their room or go on outings with family members. They also said that a guitarist visits the home regularly. Another said they enjoy watching sport on the television and would ensure that they watched the tennis at Wimbledon. Many residents commented that their friends and relatives could visit at any time. One resident said that they enjoy playing bridge and that their friends come to the home to participate in this activity with them. They stated that the staff help to ensure the table is prepared for this pastime. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 13 There is an activities programme provided at the home which includes a weekly quiz, keep fit, poetry and bingo. The Manager reported that a pianist was going to be providing entertainment at the home that evening. The Manager reported that the hairdresser visits weekly and there is a separate room for this purpose. One resident stated that they have their ‘hair done once a fortnight.’ One resident reported that they had recently attended a friend’s birthday party and that they enjoy attending church regularly. The Manager said the menus are rotated on an eight-weekly basis and the resident’s opinions are always sought. Residents are given menus at the start of each week and choose from this – they may also make suggestions or ask for alternatives if they would prefer to have a different choice. The inspector observed that the tables were attractively laid for lunch and residents were seen to eat in a relaxed atmosphere chatting to each other. Comments about the food were very positive, one resident stated ‘ the food is marvellous’ another said the food was ‘lovely’ and ‘you have a choice of two meals every mealtime’. This resident also commented they had specialised dietary needs and that ‘ they cater for me very well.’ St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16, 18 An appropriate complaints procedure is accessible to residents. Their rights are protected and systems are in place to protect them from abuse. EVIDENCE: A complaints procedure is in place at the home and can be found in all the resident’s guides. The Manager reported that there have been no formal complaints since the last inspection visit. An accident log is kept at the home and any incidents were seen to be fully recorded with details of the time, date and what action was taken. An organisational abuse policy is available at the home and the home also has a copy of the London Borough of Richmond Protection of Vulnerable Adults Policy. A Whistle blowing Policy is also in place and a staff member spoken to demonstrated a thorough knowledge of this policy and it’s importance. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Residents live in a safe, well-maintained environment. The communal areas are homely and well decorated. Resident’s bedrooms are personalised and comfortable and they have their own possessions around them. EVIDENCE: There are two lounge areas which are very homely and comfortable and contain bookcases, plants and fish tanks. One is situated to the front of the house and there is also a conservatory lounge which leads out to an attractive, large well-maintained garden which contains a gazebo and mature shrubs and trees. A new storeroom has been built in the garden. The Manager reported a professional assessment of the premises by an occupational therapist or equivalent has not yet been obtained. This requirement remains outstanding from the last inspection. There is a passenger lift available at the home. Suitable bathroom and toilet facilities were seen to be in place throughout the home. In one residents WC the toilet seat is loose and requires repair. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 16 All bedrooms seen were observed to be clean, comfortable and well personalised to individual residents taste. Residents can bring in personal items and pieces of their own furniture. The Manager reported that some of the bedrooms are being redecorated. All areas throughout the home were found to be very clean and hygienic. The Manger said she takes pride in ensuring high standards of cleanliness at the home. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29, 30 Staff are enthusiastic and deliver a good standard of care. They have a good knowledge of resident’s needs and a conscientious attitude to their work. EVIDENCE: Residents were very complimentary about the staff and the care given at the home. One resident commented ‘All the carers are very nice people’, another said ‘They are very kind.’ Another resident reported that the ‘staff are wonderful.’ Many staff at the home have worked there for a number of years and have built up a good knowledge and understanding of the needs of each resident. Staff were observed to be helpful and professional and to have a good rapport with residents and to respect their dignity and privacy. Two staff files were seen and were found to contain all the required documentation including criminal record checks and references. Although staff meetings have taken place they have been held on an infrequent basis, however the Manager stated she is addressing this and will hold them more frequently. Issues discussed at the last meeting included staff supervision, medication and the employee handbook. Two members of staff are NVQ Assessors and have completed the NVQ Level 2 and applying for the NVQ Level 3. Two further members of staff are completing the NVQ Level 2 and one has registered to undertake this course. One member of staff confirmed they have recently attended Medication training and Moving and Handling training. They also demonstrated a good knowledge of adult abuse procedures and whistle blowing. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 18 There is a comprehensive structured staff induction programme in place at the home, both organisational and to Foundation level. All staff complete a handbook over a six week period. The Foundation training is completed over six months. The members of staff who are NVQ assessors oversee the induction programme and provide support to new members of staff. This training is carried out on a one to one basis. Staff supervision is taking place regularly and a staff member spoken to said they felt well supported. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 38 The Manager has an open and inclusive management style. The Manager provides clear direction and leadership within this home and is committed to maintaining high standards of care for the residents and ensuring it is run in their best interests. EVIDENCE: The Manager is very involved in the day-to-day running of the home and adopts a very ‘hands on’ approach. One resident said ‘You can always talk to her’ and she ‘does an excellent job.’ Many residents commented on how well the home is run. The Manager has obtained the NVQ Level 4 and the Registered Managers Award and has many years experience. The Manager said that she places a strong emphasis on respecting the privacy and dignity of the residents. There is a quality assurance programme in place and completed questionnaires have been returned from residents and relatives. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 20 A comprehensive set of policies and procedures is available at the home. First aid boxes are not always being checked monthly and the Manager said she would ensure this is done. Also, the fire alarm system although being checked frequently will require weekly testing. Other records relating to health and safety were found to be up-to-date including: portable appliance testing, gas safety and lift servicing. The manager reported that all bath temperatures are tested prior to each resident having a bath. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 3 2 3 3 3 4 STAFFING Standard No Score 27 x 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 4 3 x x 3 x 2 St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 22 Yes 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 OP7 Regulation 13 (4) 15 (2) Requirement The Registered Person must ensure that: 1. Careplans are reviewed monthly and this is fully recorded. 2. Risk assessments are in place for all service users The Registered Person must ensure that the maintainence issues outlined in Standard 19 of this report are addressed. The Registered Person must ensure that an assessment of the premises is completed by an Occupational Therapist or another suitable qualified person. The Registered Persons must ensure that the fire alarm system is tested weekly and this is fully recorded. Timescale for action 1st September 2005 2. OP19 23 (2) (b) (b) 13 (4) (a) 1st September 2005 1st September 2005 3. OP22 4. OP38 12 (1) 13 (4) 23 (4) 1st July 2005 5. 6. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 23 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 OP38 Good Practice Recommendations The Registered Person must ensure that all first aid boxes are checked monthly and fully recorded. St Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Ground Floor 4`-47 Hartfield Road Wimbledon London SW19 3RG 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 Marys House G54-G04 S17391 St Marys House V229405 210605 Stage 4.doc Version 1.30 Page 25 - 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!