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

Also see our care home review for St Mary`s House Residential Home for more information

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 Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a friendly and homely feel, the staff was observed to be very caring and having a good rapport with the residents. One staff member spoken to said that they had worked in the home for sixteen years and this in itself was an indication of how much they liked working there. A resident spoken to is the third generation to live in the home, this does indicate the stability of the home and the continuity of care. The manager and the provider being the husband and wife team that run the home are very committed to providing the best care possible. During the inspection they were both observed to explore every option to improve services to their residents.

What has improved since the last inspection?

The home had two requirements and three recommendations at the last inspection. The issue of fire doors wedged open has been addressed and during this inspection, no fire doors were found to be wedged open. The other issue over a resident being locked in their room has been addressed by a device being fitted to their room. This informs staff if any other resident is wandering into their room at night and has also been fitted to other resident`s bedroom doors as well. Residents files looked at had been laid out in a clear format that gave all the staff the information that they needed. This inspection to the home took place on a very cold day and residents indicated that do find going out in weather like this difficult. However it was documented and established with the manager that all the activities and visitors to the home give residents external contact.

What the care home could do better:

The home do have a number of staff on training and effectively they are reaching levels of training that exceeds the National Minimum Standard. However the home does not maintain a documented programme of development and training, which is required by the National Training organisation (NTO).

CARE HOMES FOR OLDER PEOPLE St Mary`s House Residential Home Earsham Street Bungay Suffolk NR35 1AQ Lead Inspector Helen Fontaine Unannounced Inspection 1st March 2006 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 Residential Home DS0000024499.V285418.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 Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s House Residential Home Address Earsham Street Bungay Suffolk NR35 1AQ 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) 01986 892444 01986 895708 Mr Christopher Albert Farrer Mrs W Farrer Mrs W Farrer Care Home 28 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (19), Old age, not falling within any other of places category (9) St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 The home may accommodate up to one person, aged 60 and over, who require care and accommodate by reason of dementia. 4th March 2005 Date of last inspection Brief Description of the Service: St. Mary’s House Residential Home is registered to provide care for 28 older people. Of these, up to 19 places are for older people with dementia, and 1 place for a person aged between 60 to 65 years of age. The home is situated in the market town of Bungay, close to shops, Post Office, public houses, Hotel, Library, Doctors surgery, Dentist, Optician, and restaurants. A bus service links it to the main towns, including Norwich and Lowestoft. St Mary’s House is a large adapted Georgian property. Residents’ bedrooms, toilets and bathrooms are located across all 3 floors. Communal rooms lounges/dinning rooms are on ground level, and have doors leading out to the patio and mature gardens. Residents can move around the home by using the passenger lift, platform lift, stair lift, stairs or ramp. A ramp is located to the rear of the home, to enable disabled, or wheelchair users access. There are 7 car-parking bays at the rear of the home. There is also off-street parking, and Pay & Display car park within walking distance. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of St. Mary’s House took place over four hours and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Two requirements and three recommendations were set at the previous inspection. No new requirements and only one new recommendation were given at this inspection. The homes manager was present during the inspection and their assistance was very much appreciated. The registered provider was present during the second half of the inspection, residents were spoken to and one individually and a member of staff was spoken to. What the service does well: What has improved since the last inspection? The home had two requirements and three recommendations at the last inspection. The issue of fire doors wedged open has been addressed and during this inspection, no fire doors were found to be wedged open. The other issue over a resident being locked in their room has been addressed by a device being fitted to their room. This informs staff if any other resident is wandering into their room at night and has also been fitted to other resident’s bedroom doors as well. Residents files looked at had been laid out in a clear format that gave all the staff the information that they needed. This inspection to the home took place on a very cold day and residents indicated that do find going out in weather like this difficult. However it was documented and established with the manager that all the activities and visitors to the home give residents external contact. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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 Residential Home DS0000024499.V285418.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 Residential Home DS0000024499.V285418.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): 3 People who use this service can expect to have their needs assessed before moving into the home. EVIDENCE: During the inspection the file of the newest resident was looked at, this resident had moved to the home from another county. Due to the distance the home was not able to do their own assessment, but had information from the hospital and family. Another County Council are funding this resident and on file there was details and a written contract. The homes own pre-admission form had been completed and in addition to this was the discharge form from the hospital. The homes own pre-admission form completed through information gained, covered personal details and what the resident liked to be called. It also covered areas like medication history, mobility needs, personal care, continence, skin condition and memory. The whole document covered two sides of an A4 sheet but covered all the necessary areas and was easy to read. The hospital discharge form covered personal details, mobility, orientation, skin condition and aids to daily living. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 9 There was on the documentation concern over the distance the resident would have to travel and the manager indicated that although they had settled in well, their mobility deteriorated. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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 People who use this service can expect to be treated with respect, have their health needs met and have an individual plan of care drawn up. Residents can be assured that they are protected by the homes polices and practices around medication. EVIDENCE: At the last inspection the home received a recommendation around the information on the residents care plan. The home have now devised a new format for their care plans and two were looked at during the inspection. The form was precise but covered all the necessary areas, giving staff clear and up to date information. The file of the newest resident and a resident needing District Nurse input, care plans were looked at. Since the last inspection the home have developed a new form and this was headed St. Mary’s House, Residential Care Plan, and six-month review. It had what the resident liked to be called, who will visit, diagnosis, diet with likes and dislikes, size of appetite and all other necessary areas. The resident who had the District Nurse visiting had a skin care problem and the file had on it, the nutritional assessment, body mass index, the malnutrition universal screening tool (MUST) and the waterlow score. As the St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 11 resident had skin care problems there was a section for the pressure sore plan of treatment detailing the necessary care by the staff and one being the frequent turning at night. The District Nurses keep their clinical notes in the home with the homes care plan and seen on the file was the daily recording which showed visits from the District Nurses. Issues around medication were looked at and the homes medication is kept in a locked cupboard. Most of the medication is in bubble packs and these are set out in times of day that they are prescribed for. All the liquid medication and medication not in the bubble packs are kept in sections in the cupboard. The Manager said that Medicine Administration Record (MAR) sheets are checked and the medication is put in the medication trolley. The liquids and other medication is put in little cups or dishes with the residents name on and then put in the medication trolley. The member of staff then takes the locked medication trolley around the home with the Medicine Administration Record (MAR) sheet. The Medicine Administration Record (MAR) sheets were looked at, all had the name of the resident, date of birth, photo and were completed appropriately. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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 The home provides a range of interesting and stimulating activities for service users. Friends and families are encouraged to visit and routines within the home are flexible. EVIDENCE: At the last inspection the home received a recommendation around social contact with external agencies such as volunteers or befrienders. The manager said that they had explored the issue of volunteers or a befriender, but all their approaches were turned down when the person had to get a Criminal Record Bureau (CRB) before they could work with anyone in the home. One resident spoken to, said that during the summer they do get out most days and visit shops. However the resident said that at the moment the weather was too cold and the pavements were slippery. The resident said that they usually go out at least once a fortnight with the Registered provider, but would not go out until the weather gets warmer. After discussion with the manager and Registered provider, it was evident that quite a number of visitors to the home come to provide the residents with entertainment and activities. The home does take residents out to quite a few community activities like the Christmas pantomime. The home is right in the centre of the village of Bungay and every year the village hold fair and close the road, all the residents able go out and one resident used to run their own St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 13 stall at the fair. The manager indicated that in good weather two residents go out regularly. The home also very much encourage relatives and friends to visit the home and the manager said that one family member comes every afternoon. Another had a relative and the home supplied lunch for them both. Another resident has their family member visits very often. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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): 18 People who use this service can expect that any complaint will be taken seriously and investigated and that they will be protected from abuse. EVIDENCE: During the inspection a resident and a member of staff were talked to individually. The resident was asked about complaints, concerns and if they felt safe living in the home. The resident said their grandmother used to be in the home and so did their mother and they felt very safe living in what they feel is a real home for them. They said that they would be able to tell any member of staff about any concern and had done so. The member of staff said that they had worked in the home for some sixteen years and this was because they felt the home was so good. When asked about residents being safe, they were very clear that any kind of problem would be dealt with straight away. The home received a requirement and a recommendation from the last inspection. These were about a resident having their room locked at night, this has now been stopped and a device has been fitted to the bedroom door. This device alerts staff to any other resident entering their room during the night, as the home does have residents that wander at night. The resident spoken to also said that they actually lock their own bedroom door at night and they have a key and the staff can enter with a key. The resident said that a resident who sometimes wanders is in a room next to them and they do come into their room if it is not locked. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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, 20 and 25 People who use this service can expect to live in a clean, well-maintained home, in personalised rooms. EVIDENCE: The home is in the centre of the village of Bungay, it is a beautiful building, which has been carefully modified to meet the needs of the residents. The home had a real homely feel and was ever so clean, without being clinical. The residents that were happy for the inspector to visit their rooms, these were looked at and all found to be individually personalized. The home has a variety of lifts, ramps and chairlifts that gives access to all areas of the home. There are two separate lounges, with dining room areas and a quiet area where residents can sit or take visitors. All the bathrooms looked at had equipment to give access to a bath and all of them were warm and well ventilated. One of the bathrooms had a specialized overhead hoist to allow access to a bath for the most disabled resident. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 16 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): 28 and 29 The home recruitment practices are robust and offer protection to service users. Staff are trained to do their job. EVIDENCE: The homes staff training was looked at and ten staff have the National Vocational training (NVQ) level three and three staff in the process of doing the qualification. Eleven staff have achieved National Vocational Training (NVQ) level two and two staff are National Vocational Training (NVQ) assessors. This does mean that the home has more than 50 of its staff attaining the necessary qualification and exceeds the National Minimum Standard. The manager indicated that the only remains few staff not currently on a National Vocational Training (NVQ) course, are those who do not want to do the training. During the inspection, the newest member of staffs file was looked at. The file contained the Criminal Record Bureau (CRB), staff supervision form completed, job application form, two references, job description, copy of the birth certificate and the Protection of Vulnerable Adult (POVA) first check. Also on the file was an assessment question paper, health declaration form, terms and conditions, staff training. Although the manager was able to produce a list and displayed in the home were lots of training certificates, there was no staff development programme documentation that meets National Training Organisation (NTO). St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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, 35 and 38 This home is well managed and there are clear systems in place to protect service users. EVIDENCE: Mr and Mrs Farrer are both very much involved in the running of the home, with Mrs Farrer being the registered manager. Mrs Farrer has been the manager of the home for sometime. The issue around the resident’s personal finances are not dealt with by the home and the families or a representative deals with any issues around money. One resident who manages their own personal finances, goes with Mr Farrer the Registered provider once a fortnight and gets what money they need. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 18 At the previous inspection there was a requirement around the fire doors being wedged open. During the tour of the home there were no fire doors wedged or propped open. All the doors were either held open by appropriate equipment or they were shut. St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 X X X X 3 X STAFFING Standard No Score 27 X 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 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. Standard Regulation Requirement Timescale for action 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 OP30 Good Practice Recommendations It is suggested that the home develop a staff training and development programme, which meets the National Training organisation (NTO). St Mary`s House Residential Home DS0000024499.V285418.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Residential Home DS0000024499.V285418.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. 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