Inspection on 22/11/05 for St Mary`s House

This inspection was carried out on 22nd November 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 21/06/05

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 Mary`s House 71 Ormond Avenue Hampton Middlesex TW12 2RT Lead Inspector Sharon Newman Unannounced Inspection 22nd November 2005 10:00 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 DS0000017391.V266848.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 DS0000017391.V266848.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Mary`s House Address 71 Ormond Avenue Hampton Middlesex TW12 2RT 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) 020 8979 2847 stmaryshouse@dial.pipex.com Ms Sylvia Warren Mrs Sylvia Warren Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Sensory impairment (24) of places St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 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 Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 22nd November 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 and medication records. A tour was also taken of the premises. The Manager was very helpful throughout the visit and remains genuinely committed to her work and to the residents. Staff were observed to have a good rapport with the residents displayed a kind and gentle manner when talking to or assisting them. Residents spoken to were very positive about life at the home. One resident said ‘I am very well looked after here and never want to leave.’ What the service does well: What has improved since the last inspection? What they could do better: Areas for improvement were discussed with the manager at the time of the inspection. These include making sure that residents care plans are reviewed monthly and that risk assessments are in place for all residents who need bed rail equipment. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 6 Medication administration records must be fully completed for all items of medication including creams. Requirements have been made regarding maintenance issues at the home and these are outlined in the environment section of the report. Also, an occupational therapy assessment of the premises still needs to take place. Attention needs to be paid to staff training to ensure that all staff are up-todate with their mandatory training and staff supervision needs to take place at regularly. All cleaning products (COSHH) must be kept locked away securely. 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 DS0000017391.V266848.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 DS0000017391.V266848.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. 2. 3. 4. This home provides good information to residents to enable them to make decisions about their care. This home continues to place 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: The Statement of Purpose is in place and remains unchanged from the previous inspection visit. It contains information about: the staff and the organisational structure, assessment visits by the Manager, activities available and complaints. The Residents Guide (Service Users Guide) is comprehensive, informative and detailed. It contains: the home’s terms and conditions, resident’s rights, the complaints procedure, meals and activities. Contracts were in place for three residents whose files were seen. Assessments of their needs were also in their files. One resident commented ‘I am very lucky – this is a lovely home.’ Another said ‘I am very happy here.’ Another said ‘I have settled in well here – I really like this home.’ St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 9 St Mary`s House DS0000017391.V266848.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. 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 appropriately. Attention needs to be paid to recording on the medication administration records to make sure residents are not placed at risk. The lack of a risk assessment for bed rail equipment could place residents at risk. EVIDENCE: Three care plans were looked at during this inspection visit. As reported in the previous inspection report 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. There was no evidence seen to suggest that care plans were being reviewed monthly and this needs to be done. The manager said she was addressing this and has drawn up some paperwork to ensure that both care plans and risk assessments are updated monthly. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 11 A risk assessment was not in place for a resident who had bed rail equipment. Risk assessments must be in place and must demonstrate family and resident involvement in the decision and the input of relevant healthcare professionals. Evidence was seen in care plans of input from health care professionals including: occupational therapists, GP’s, community nurses and social workers. The manager reported that District Nursing input is provided regularly to the home and the GP visits weekly. She also said that an NHS chiropodist visits the home 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. One resident said that ‘the doctor, diabetic nurse and chiropodist visit the home’. The home needs to make sure that all medication administration records (MAR) are fully completed as two omissions were found on one MAR sheet relating to administration of creams. Medication was stored securely within a locked cupboard on the day of inspection and is provided in a monitored dosage system There are comprehensive medication policies in place at the home, including one for homely remedies, disposal of medicines and a selfmedication policy. Residents were observed to be treated with kindness and dignity by staff. They were observed to be offered choice by staff as to where they wished to sit in the lounge area. Privacy is respected and there is an adapted room that can be used for medical appointments or by the hairdresser. Many residents have telephones in their own rooms. St Mary`s House DS0000017391.V266848.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. 13. 14. 15. The home continues to ensure that 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: Visitors were seen to be welcomed to the home and chatting freely with their relatives. The manager said refreshments are always offered and visitors may stay for lunch or afternoon tea if they wish. One resident said that ‘the staff always gives our visitors tea and biscuits and they may stay for lunch if they wish.’ There is an activities programme provided at the home which includes a weekly quiz, armchair keep fit exercises, and bingo. The manager reported that a pianist was going to be providing entertainment at the home that evening. She said that the hairdresser visits weekly. A resident said that the manager ‘takes us on trips, we recently went to Buckingham Palace.’ They also reported that the residents were taken on a barge trip recently and that musicians visit the home. As reported in the previous inspection report the menus are rotated on an eight-weekly basis and the resident’s opinions are always sought. Residents St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 13 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. Some residents commented about how much they enjoy having breakfast in bed. The inspector observed that the tables were attractively set for lunch with tablecloths and linen napkins. Residents were seen to eat in a relaxed atmosphere chatting to each other. Those residents who needed assistance were helped discreetly and with dignity by staff members who sat beside them. Three courses are offered for lunch each day and then afternoon tea is served in the afternoon. Residents are offered a choice of meals and vegetarian and health needs such as diabetes are catered for. A light supper is offered daily and drinks and snacks are offered at 10 pm. One resident said ‘I have Ovaltine at night.’ Comments about the food were very positive. A resident said ‘the food is very good, you have at least two choices.’ St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 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 the following 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: The home has an organisational abuse policy and a copy of the London Borough of Richmond Protection of Vulnerable Adults Policy. A Whistle blowing Policy is also in place. There is a complaints procedure at the home and this can be found in all the resident’s guides. No complaints have been received by the Commission for Social Care Inspection and the manager reported that there have been no formal complaints since the last inspection visit. A resident reported that they did not have any complaints and if they did they would feel confident to approach the manager to discuss any issues. The manager reported that either the residents’ families or their solicitors were responsible for their finances. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 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 the following standard(s): 19. 22. 23. 24. 26. Residents live in a homely and attractive environment. The communal areas are well decorated. Resident’s bedrooms are personalised and comfortable and they have their own possessions around them. The home is clean and hygienic. EVIDENCE: There are two lounge areas which are homely, comfortable and well decorated. These contain comfortable armchairs, bookcases, plants and fish tanks. The conservatory lounge leads out to an attractive, large well-maintained garden which contains mature shrubs and trees. A storeroom is situated in the garden. The dining area has four large tables and is clean and pleasant. The manager reported a professional assessment of the premises by an occupational therapist or equivalent has still not been obtained. This requirement remains outstanding from the last two inspection visits and must be obtained. The manager said she is addressing this issue. Some maintenance issues were identified at the time of inspection and were discussed with the manager. A ceiling light bulb was not working in one of the St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 16 hallways and a further light bulb on the top floor ceiling was continually flickering. There was no light bulb in the light fitting at the top of the stairs. A resident expressed their concern about the flickering light bulb and stated that they found the top floor corridor and the stairwell too dark. The stair carpet is worn and requires replacement. Some paintwork on ceiling areas in the hallways and at the top of the stairs was cracked and requires redecoration. The flooring in the first floor bathroom was observed to be marked and stained and will need to be replaced. Suitable bathroom and toilet facilities were seen to be in place throughout the home. However, in one residents WC the toilet seat is loose and requires repair. Resident’s bedrooms were seen to be personalised to individual taste. Residents have their own furniture and belongings in their rooms. One reported that they have a ‘very comfortable room.’ All areas throughout the home were found to be clean and hygienic at the time of inspection. The manager reported that the bedrooms are cleaned everyday and ‘spring cleaned’ every four weeks and there is a rota in place for this. A resident said that ‘the standard of cleanliness is good.’ There is a passenger lift available at the home. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 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 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. 30. Staff are enthusiastic and deliver a good standard of care. They have a good knowledge of resident’s needs and have a conscientious attitude to their work. EVIDENCE: One resident stated that all the staff are nice people.’ Another commented about the ‘very kind staff.’ Staff were seen to have a very good rapport with the residents and to assist them with kindness. The manager reported that she valued her staff team and thought highly of them. She said they all work well as a team. She reported that the two team leaders have now completed their NVQ Level 2 training courses and that they are both NVQ assessors. This is an advantage to the home as it means that they can assess other staff who are completing their NVQ training at the home. The manager said that in total eight staff have completed their NVQ Level 2 and two more are currently undertaking this course. One member of staff who was involved in food preparation did not have the Food Hygiene course. All members of staff involved in the preparation of handling of food should be up-to-date with this training. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 18 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. 33. 36. 38. The Manager has an open and inclusive management style. She 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. However, residents may be at risk of harm due to cleaning products not being locked away securely. EVIDENCE: As reported in the previous inspection report the manager is very involved in the day-to-day running of the home and adopts a very ‘hands on’ approach. One resident commented that the manager always stresses to them ‘this is your home.’ Another said that the manager ‘gets on with everyone.’ The manager has obtained the NVQ Level 4 and the Registered Managers Award and has many years experience. The Manager continues to place a strong emphasis on respecting the privacy and dignity of the residents. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 19 The manager said that not all staff are receiving one-to-one supervision but that she was going to address this. All staff need to receive supervision at least six times a year, pro-rata for part-time staff. Cleaning products were found in many of the WC’s and bathrooms throughout the home. These must be locked away securely in accordance with COSHH regulations. An Immediate Requirement was issued in respect of this issue at the time of inspection. A comprehensive set of policies and procedures is available at the home. A five yearly electrical installation check was not available at the time of inspection and must be obtained. This is particularly important due to the issue with the flickering light fitting on the top floor hallway. The manager reported that she would ensure that this was addressed. The fire alarm system is now being checked weekly. Other records relating to health and safety were found to be up-to-date including: portable appliance testing, gas safety and lift servicing. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 20 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 X 2 St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 21 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 Regulation 13(4) 15(2) Requirement The Registered Person must ensure that service user plans are reviewed monthly and this is fully recorded. Previous timescale of 01/09/05 not met. The Registered Person must ensure that risk assessments are in place for all service users with bedrail equipment. These should be subject to advice from relevant health care professionals. The Registered Person must ensure that the medication administration records are fully completed by staff administering medication. The Registered Person must ensure that the maintenance issues outlined in Standard 19 of this report are addressed. Previous timescale of 01/09/05 not fully met). The Registered Person must ensure that an assessment of the premises is completed by an Occupational Therapist or another suitable qualified DS0000017391.V266848.R01.S.doc Timescale for action 01/01/06 2 OP7 13(4) 01/12/05 3 OP9 13(2) 01/12/05 4 OP19 23(2)(b) (b) 01/02/06 5 OP22 13(4)(a) 01/02/06 St Mary`s House Version 5.0 Page 22 6 OP30 18(1) 7 OP36 12(5) 8 OP38 13(4) 9 OP38 13(4) person. Previous timescale of 01/09/05 not met. The Registered Person should ensure that all mandatory staff training is up-to-date. This is in particular regard to food hygiene training for all staff involved in the preparation and handling of food. The Registered Person must ensure that one-to-one staff supervision takes place at least six times a year. Pro-rata for part time staff. The Registered Person must ensure that all cleaning products and bleach (COSHH) are locked away securely. Immediate Requirement issued at the time of inspection. The Registered Person must ensure that the five yearly electrical check is carried out and a certificate obtained. 01/02/06 01/02/06 22/11/05 01/01/06 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. Refer to Standard OP7 Good Practice Recommendations The manager should consider ensuring that risk assessments are subject to the same review as care plans. St Mary`s House DS0000017391.V266848.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 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. 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