Inspection on 31/10/07 for St Mary`s House Residential Home

This inspection was carried out on 31st October 2007.

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.

Other inspections for this house

St Mary`s House Residential Home 28/06/06

St Mary`s House Residential Home 01/03/06

St Mary`s House Residential Home 10/10/05

St Mary`s House Residential Home 04/03/05

St Mary`s House Residential Home 13/01/05

St Mary`s House Residential Home 17/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta 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 Residential Home Earsham Street Bungay Suffolk NR35 1AQ Lead Inspector Mary Jeffries Key Unannounced Inspection 31st October 2007 15:00 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.V354033.R01.S.doc Version 5.2 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.V354033.R01.S.doc Version 5.2 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 cw.farrer@btinternet.com 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.V354033.R01.S.doc Version 5.2 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. 28th June 2006 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.V354033.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. An annual quality assurance assessment (AQAA) was sent to us by the service. Pre inspection Surveys were returned to us by people using the service and from other people with an interest in the service. Six service user, five relative/visitor and four staff surveys were completed and returned to CSCI. The inspection took place on an afternoon and early evening in October and took five and a half hours. The manager facilitated the inspection, and other staff participated. Three residents were tracked. Two periods of observation of staff and residents in the two lounges occurred. One resident who did not have dementia was spoken with in some depth. A number of documents were examined including residents’ care plans, medication records, training records and records relating to health and safety. A tour of the communal areas and some bedrooms was undertaken. What the service does well: The home has a friendly and homely feel. The pre inspection surveys returned to the CSCI were complimentary and there were no criticisms other than staffing which is generally seen by service users and relatives to be at a very good level, but which can be less than very good during holidays and sickness. The home has developed an internal quality assurance tool based on residents’ opinions which it has used to influence changes in the home. Residents files looked at had been laid out in a clear format that gave all the staff the information that they needed. Staff felt supported in their work by the management. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 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.V354033.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home, can expect their needs to be fully assessed. This ensures that the home only admits residents within their registration category, whose care needs they can meet. EVIDENCE: The Service User Guide (SUG) did not contain details of fees. It is otherwise a comprehensive document but was not up to date in that it states that communion is held in the home; the manager has confirmed that at present there are no church services. Also the SUG states that 3 carers in addition to the head of care hold NVQ3, the AQAA states that 17 staff are now qualified to NVQ2. The Service User Guide states that residents are encouraged to visit prior to admission, the head of care advised that often the relatives visit rather than St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 9 the prospective resident, but that a preadmission assessment of need is always carried out. The AQAA stated that no residents had been discharged during the previous year as a consequence of them being inappropriately placed. The care plans of three residents were inspected; two of the residents had been admitted since the last inspection. All three care plans had a pre admission assessment. These assessments included information about the resident’s physical and mental health, recreation and social care, safety, communication, falls, personal hygiene and the reason for their admission. All six residents who completed surveys said they received enough information to make a decision about the home. Four out of five relatives who responded stated that they always get enough information about the home, one stated that they usually did. The AQAA stated that the home does not provide intermediate treatment. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can have a comprehensive care plan that is regularly reviewed, they can expect staff to have a good knowledge of their health care needs and to have good access to medical services. EVIDENCE: The care plans and associated records relating to three residents were examined. These were discussed with a senior staff member. All four staff members who responded to the survey indicated that they were given up to date information about the needs of the people that they support and care for. Each of the residents had a care plan that had been reviewed and updated where appropriate on a monthly basis. The plans had several elements to it including communication, being safe, personal care, dressing, eating and drinking, sleeping, mobility and recreation needs. The plans all contained an St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 11 assessment of mobility, as appropriate, and use of a frame/wheelchair. There were clear instructions to staff on how to move and handle the individual resident. Waterlow tissue viability risk assessments and nutritional screening were in place where indicated. One resident who was tracked had a risk assessment for bedsides in place; this had not been countersigned by a relative or other professional. The care plans were clear and easily understood. The residents tracked also had life story sections of their care plans, however a senior member of staff was asked about the history of one resident with dementia and they did not know if they had had an occupation or what that was. They were asked about another and were aware of some aspects of their previous life; they were asked how they knew this and they said that they had picked it up from what the resident had said. The member of staff did however have a good knowledge of each resident’s health care needs. There was evidence of accessing health care from the chiropodist and regular contact with and visits from general practitioners. All six residents who returned a survey stated that they receive the care and support that they need. Four out of five relatives indicated that the home always meets the needs of their relative, one stated that the home usually does. Four out of five relatives indicated that the home always meets the needs of different people, one thought that it usually did. A requirement was made at the last key inspection regarding standard 9, that all staff who administer medication must adhere to the procedures for the recording of medicines. The medication protocol was inspected at the last inspection. The manager advised that this had not changed since then. The AQAA stated that there had been no serious incidents involving the mismanagement of drugs in the last 12 months. No regulation 37s had been returned to CSCI in respect of medication errors. The tea time medication round was observed. The senior staff 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 and all had the name of the resident, date of birth, photo and were completed appropriately. The carer administering medication was seen to handle the tablets given out routinely through the administation of the round. On one occasion she popped it directly into the resident’s mouth by hand, the resident was asked first if they wanted this done, and the manner of the member of staff was generally St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 12 very good, however this practice is not necessary and is not acceptable as tablets can become contaminated. Eye drops were seen to have been dated when opened. Medicine bottles all had recent dates,and the member of staff advised that any left go back each fortnight and a new bottle is provided if needed. The medicine administration record (MAR) sheets were inspected and no errors or gaps in recording were found. However in two cases a medication had been handwritten onto a MAR sheet, and in one record a dose had been altered, and these changes had not been signed or dated. Five residents stated that they always receive the medical support that they need, one stated that they usually receive the medical support that they need. Staff interaction with residents was generally seen to be polite and respectful, although a busy period at tea time was less than good for some residents, this is detailed in the next section. A resident spoken with advised that it was their home, and that staff showed them every respect, for example that they wouldn’t think of coming into their room without knocking. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can expect to be served varied, nutritional meals, and to enjoy a range of interesting and stimulating activities. EVIDENCE: Residents have a choice of places in the home where they may spend their day and are free to move around the home. One resident who advised they had been at the home for many years was seen sitting at a small table in a nook, later they were seen sitting their doing craft work. This resident said that they didn’t have many visitors, having grown so old, but that they could have visitors whenever they wanted, and that others did. Another resident wandered into the manager’s office at two different times in the day, they were responded to nicely on both occasions. All six residents responding to the survey stated that there were activities arranged by the home that they could take part in, although one stated that they chose not to. The AQAA stated a range of activities, but noted that the home finds it hard to find activities for some residents who have dementia to engage in. The visit took place on Halloween, and the residents were having an St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 14 afternoon party with a special cake. A number of staff had dressed up for the occasion. Some staff who were off duty called in with their children who were also dressed up, to show the residents their efforts. This was well received by the residents. A member of staff advised that all houses in the main street in the village displayed pumpkin lanterns on this night. This activity was in keeping with local tradition. In the Foyer there was a list of social events to be held during November. These included a bonfire display and late supper, two afternoons with (different) musical entertainers, a visiting local theatre company, and the Remembrance service on television. The AQAA stated that the home is seeking to establish a list of church goers who would assist to escort residents to church. The manager advised that presently there are no church services held in the home. The AQAA noted that some residents would like to go to church but that staff availablity precludes this. There was a period prior to tea time when six residents with dementia were left without stimulation and with little attention for nearly forty minutes. During this time, the carer doing medication came into the room, and another member of staff looked in briefly. Two residents were speaking, partly to themselves and partly to each other. One was quite distressed and expressing concerns and regrets about their life repeatedly, the other was grumbling crossly. During this time two residents were asleep, another was showing by their facial expression that they were exasperated by the two who were unhappy and the sixth was clapping their hands, but did not have a happy demeanor. They then started to hitting the tray in front of them with a cup and saucer and calling out in distress. The manager advised that the period before tea was a time when there was not a lot going on, but apprecated that leaving a number of residents with dementia alone and without stimulation was less than good. Tea time was observed in this lounge. Three carers were involved in assisting, two left the room several times to get napkins. During this time the resident who had been calling out asked four times if they could have theirs now; they were told by a carer that they would get theirs in a minute. This transpired to be after the three who needed assistance had been fed. This person and another had to wait unnecessarily for their food that they had asked for, whilst seeing others eating. Five out of six residents stated in their surveys that they always like the meals, one stated that they ususally like the meals provided. The resident spoken with said that the food was very good, and that they could always have something different if they didn’t want the main meal. The main meal on the day of the inspection had been pork ragout, broccoli and green beans. Residents could choose from a number of alternatives. The menu was written; there were no picture menus to assist those with dementia make choices or stimulate appetites. The home had undertaken its own survey that included a question St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 15 on the home’s food and menu. Fifteen out of seventeen who completed it rated the food as very good or good, five did not comment. One resident advised that they could have breakfast in bed, and liked this. All five relatives indicated that the home supports people to live the life they choose. One commented that they thought the service did well in treating the residents, as individuals, and cares for them as such. They noted that the home establishes a good attitude amongst staff and residents. The homes AQAA stated that they had enlisted the help of a local restaurant to provide appropriate food for a resident who is a member of an ethnic community. All five relatives who responded to the questionnaire stated that they were always kept up to date with important issues affecting their relative. The visitors book showed that frequent visitors called at the home. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to have access to a proper complaints procedure and can expect management to respond to any concern raised helpfully. EVIDENCE: All six residents responding to the survey stated that they knew who to speak to if they were unhappy, four said that they knew how to complain, one stated that they did not need to know as they had nothing to complain about, one stated that they did not know. The resident who was spoken with in some depth said that they didn’t need to complain, that they could if they wanted to but they would just have a word, adding that, “they will do anything they can for you.” Four out of five relatives knew how to make a complaint, one didnt but noted that they hadnt had to in a period of many years. Two indicated that when they had raised a concern that the home had always responded appropriately, one indicated that in their experience the home usually did. All four members of staff completing the survey stated that they knew how to respond if a resident, relative or friend had concerns about the service. A member of staff wrote that the complaints policy was on display, as is stated in the AQAA, and it was seen to be on display on the day. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 17 The AQAA stated no complaints had been received in the last twelve months.There was no log to examine. The AQAA stated that no safeguarding referrals had been made in the last twelve months. The CSCI has not been made aware of any complaints or Safeguarding issues in the last 12 months. A member of staff spoken with had an understanding of types of abuse and indicators of abuse, and was clear they would take any such concerns immedately to the manager. The manager was aware of the proper referral route for any safeguarding concerns. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to live in a clean, well-maintained home. EVIDENCE: Quality in this area were found to be good at the last key inspection when 19,20,23,24,25 and 26 were found to be met. The home is in the centre of the village of Bungay; and is a beautiful old building, which has been modified to meet the needs of the residents. The home had a homely feel and was clean, without being clinical. In the main hall of the home there is an information board, advertising forthcoming activities and events. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 19 The home spans three floors. All communal rooms are on the ground floor. Communal areas consist of a television lounge, a smaller quiet lounge and a dining room including a sitting area for meeting with visitors. The home has a variety of lifts, ramps and chairlifts that gives access to all areas of the home. All of the communal bathrooms were inspected. They 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. AQAA stated that improvements made in the last twelve months were that the ground floor bathroom has been converted into a wet room. This room was seen, it had been been fitted to a very high standard. A recommendation was made at the last key inspection that the home should provide a handrail to the stairs in the bedroom with stairs leading up to the fire exit for safe access in an emergency. This was inspected and the handrail had been fitted. Room 30 cannot be locked as a fire exit route runs through it, out onto the metal fire exit. All six residents responding to the survey stated that the home was always fresh and clean. On this occasion it was found to be clean and hygienic throughout. The home had an up to date infection control policy, and staff were aware of proper procedures for handling laundry. There were gloves and aprons available at strategic points throughout the home. A mop was seen to be stored head down in a bucket, this was pointed out as it is not a good practice for infection control. There were also towels in two communal toilets, these pose an unneccesary risk of infection, and were removed when pointed out. The AQAA identified a number of areas for improvement in the next twelve months, including redecoration of outside, improved lighting in hall and upgrading the call bell sysytem. Good lighting is particularly important for residents with some types of dementia. ‘ The kitchen was in very good order, clean and maintained to a very good standard. This room was however near to the laundry,(which is also used as staff room) but separated by a lobby area, and both rooms had the doors propped open with doorguards, which close when and if the fire alarm goes off. At the time this was seen there was no washing occurring, however, this arrangement needs reviewing from an infection control perspective as any airborne spores from the laundry could contaminate the kitchen. The laundry had been equipped with a new, additional washing machine and tumble drier. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a competent team of workers, but there maybe times in the day when the overall staffing in the home does not meet the needs of all those with dementia. EVIDENCE: All four staff members responding to the survey indicated that the staffing levels usually give them enough time to meet the residents’ needs; one made a statement that the home is usually very highly staffed, but that sickness and holidays sometimes provide shortages. The typical work rota for a morning shift is 9 carers for 28 residents, with a cook in during the mornings. The home also has two domestic workers. The AQAA stated that six residents required two or more staff to assist with their care by day, and five required two or more during the day. Twenty one require assistance with dressing/ undressing. Three pre inspection surveys from residents stated that staff were always there when they needed them, three stated that staff were usually there when they needed them. On the day of the inspection there were six staff in the home during the late shift, but one was absent between 4pm and 6 pm, leaving five staff who also had to provide tea and do the medication round. As noted under St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 21 the section of this report on daily life and social activities, the experience of a number of residents with dementia at this time of the day was not positive. Residents liked the staff, saying they were “very friendly” and approachable. An overseas carer was seen to communicate well with residents. The AQAA states that 17 staff are now qualified to NVQ2, this is almost 60 of the carers employed. A large number of these also have NVQ 3. All four staff members responding to the survey stated that they were being given training which was relevant to their role, helps them understand and meet residents’ needs, and keeps them up to date with new ways of working. All four indicated that they were receiving regular or frequent supervsion. Four of the five relatives who responded to the survey thought that the care staff usually had the skills and experience to look after people properly, one thought the staff always had. The two staff files examined showed that staff had regular updates in manual handling, some, but not all the care staff had had update training in food hygiene, which is needed given they are involved in the tea time preparation. The file of one staff member on duty that evening was inspected and contained evidence of update training. All four members of staff who responded to the survey indicated that the home carried out checks such as CRB (Criminal Record Bureau ) before they started work. The AQAA stated that the home had a stable staff group. The staff files for the two carers employed since the last inspection were inspected. Both had PoVA first checks, and were employed before the CRB; only one had had their CRB through. The manager was asked if they were supervised, and they advised that they were, but when asked said that they did not know about the change to the regulations which requires this supervision to be tightly attributed to a named person. Other information required was on file, as was evidence of a proper recruitment process, and induction. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can expect to find an approachable management and staff team, who are committed to providing a good level of service. EVIDENCE: Mr and Mrs Farrer owners and registered providers for the home are both very involved in the running of the home, with Mrs Farrer being the registered manager for sometime. Feedback given by the home, and action taken to put right any shortfalls, has been evidenced at previous inspections. The AQAA returned was clearly set out and gave us all of the information we required. It stated that one of the management team and maintenance team have been awarded National Cerificate of Further Education (NCFE) Level 2 in St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 23 Health and Safety in January 2007, and that one of the management team has attended a food hygiene and management course. Three of the four members of staff who responded to the survey stated that the ways in which information was passed between staff and management always worked well, one said that they usually did and that a new message board had been introduced to supplement the handover process. One relative commented; Management are approachable, and went on to comment,a home I would recomend. This relative was spoken with, they stated they visited very frequently and as a health care professional they were well placed to comment. Another relative commented on their survey response; “ Good communication, …always knows information when you telephone and keeps us well informed”, and a third, “In our opinion they do an excellent job.” The AQAA stated that a quality assurance exercise was undertaken in August 2006, on the basis of a questionaire to relatives, and as a response to this have upgraded bedroom furniture in many rooms. A copy of the survey was provided. All residents have a lockable drawer in their rooms. Residents’ personal finances are not dealt with by the home and, as appropriate their families or a representative deals with any issues around money. Residents are billed for additional expenditure that the home undertakes on their behalf on a monthly basis. Three residents records were examined. There was only a small amount of additional expenditure, however the invoices and receipts that the invoices were based on did not properly evidence that the expenditure had been undertaken. The home had a number of composite bills, from which an itemised list for the residents was made, but there were no signatures to evidence that the goods or services had been received by the particular resident that the invoices attributed to them. One of the residents tracked had had a short stay in hospital after a fall, a regulation 37 notice had been sent to the CSCI in respect of this. A fire risk assessment had been completed. An understair cupboard containing bleach was not locked; the key was in the lock and this was fastened immediately when pointed out. One bedroom on the top floor had a double window which did not have an opening restrictor. This window was behind a piece of furniture, and therefore did not pose a significant risk, nevertheless the manager immediately said that they would have a restrictoe put on it. The certificate of registration was displayed and correct. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X X 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5 Requirement The Service User Guide must contain all of the information required by regulation, including fee details, and must be up to date. Risk assessments for any form of restraint must be signed by the resident or a representative. Staff must not handle medication during its administration. This is to avoid contamination of medicines. Any changes to MAR sheets must be signed and initialled by the person making the change and cross referenced to a record of the instruction of the GP to do so. This is to ensure that there is accountability of any changes made to medication. Should a staff member be recruited prior to receipt of CRB, on the basis of a PoVA first check, then supervision must be put in place which meets the regulation; this is for the protection of residents. Timescale for action 30/01/08 2. 3. OP7 OP9 15(2)(c) 13(2) 20/12/07 31/10/07 4. OP9 13(2) 31/10/07 5. OP29 19(1)(b) 05/12/07 St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 26 6. OP35 17(2) schedule 4 Receipts for additional expenditure made on behalf of residents must be signed by the resident or a member of staff who can verify that they have received the item/s to safeguard residents’ finances. 14/12/07 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. 2. 3. 4. 5. Refer to Standard OP15 OP15 OP16 OP26 OP27 OP12 Good Practice Recommendations Picture menus would assist residents with dementia make meaningful choices and encourage appetite. People should take their meals in a congenial setting and should not have to wait to receive their meal whilst others in the same room are being fed. A complaints log should be started. The practice of having both laundry and kitchen doors open on automatic closures should be reviewed. Staff deployment in the late afternoons should be reviewed so that individuals with dementia are not left alone for significant periods without stimulation or emotional support. St Mary`s House Residential Home DS0000024499.V354033.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V354033.R01.S.doc Version 5.2 Page 28 - 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!