Inspection on 18/10/07 for St Mary`s Mount

This inspection was carried out on 18th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Mount 09/04/08

St Mary`s Mount 29/06/07

St Mary`s Mount 14/06/06

St Mary`s Mount 07/12/05

St Mary`s Mount 18/05/05

St Mary`s Mount 18/01/05

St Mary`s Mount 29/11/04

St Mary`s Mount 26/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Mount Holly Road Uttoxeter Staffordshire ST14 7DX Lead Inspector Jane Capron Key Unannounced Inspection 18th October 2007 09:15 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 Mount DS0000005003.V352248.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 Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Mount Address Holly Road Uttoxeter Staffordshire ST14 7DX 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) 01889 562020 01889 562020 stmarysmountenquiry@tiscali.co.uk HAS Careplus Limited Mrs Elizabeth Smith Care Home 30 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (7) St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2007 Brief Description of the Service: St. Marys Mount stands in its own grounds within half a mile of the centre of Uttoxeter where a wide range of local shops and services can be accessed. There is a town bus route passing the gateway, and the railway station is about a mile away on the other side of the town centre. There were 19 residents in the home at the time of the inspection. The dependency level of residents is varied and fluctuating. The Home is registered with the Commission for Social Care Inspection to care for a maximum of 30 older people, 14 of who may have dementia care needs and seven a physical disability. There are 28 bedrooms, 26 of which are for single occupation, and two of which are shared. There are no rooms with en-suite facilities at the current time. There is separate smoking area for residents. The present scale of fees is £357-£420 (October 2007). Other additional costs would include hairdressing, private chiropody, personal toiletries and newspapers. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days and lasted approximately 17 hours. The service did not know we were visiting. On the first day the pharmacy inspector accompanied the lead inspector to under take a full inspection of the service’s medication arrangements. We looked at the care people received including looking at whether people’s health and personal care needs were being met. We also looked at the lifestyle that people experienced including looking at the choices people had, the meals provided and the opportunities provided for people to take part in social activities. We looked at the training staff received and the way that they were recruited to make sure that people had the necessary checks to make sure that people were protected. We also looked at the accommodation including all the communal rooms and a sample of bedrooms. Before we visited the service we surveyed some people that lived there, some relatives and health professionals to gain their views about the service. We have received no complaints since the last inspection. What the service does well: The people we spoke to were happy with the care the service provided. Comments included:’ I am quite pleased with the home’, and staff ‘care for all residents with compassion’. People were positive about the attitude and care provided by the staff and we saw that staff treated people sensitively and with respect. Comments from relatives included: ‘I visit 4 times a week and have complete faith and trust in all the staff. When my wife went into the Mount all the staff were a great help’ and ‘staff have a caring attitude to residents and support residents to settle in. We saw that visitors were welcomed and related well with staff. Before any one was admitted into the service an assessment was always completed. The assessment showed people’s personal and health care needs. The service was listening to people and responded appropriately to complaints. Relatives know how to complain and were confident the service would sort out anything they raised. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 6 The service was clean throughout and staff were aware of infection control practices to control the spread of infections. The service made sure that infection control equipment was always available. The service had a system in place to review and monitor the service. This included taking account of the views of people that lived at the service and relatives. What has improved since the last inspection? What they could do better: There were still areas that the service needed to address. Most of the issues were raised at the last key inspection and had not yet been properly addressed. The service needed to make sure that the information that it provided was fully accurate and that the service did not admit people for whom it was not registered. Care plans still needed to be further developed to make sure that all people’s needs were identified. This was particularly important for people with dementia care needs. Whilst generally health care needs were being met most people were not having access to a dentist. The service’s medication arrangements needed action to make sure that people medication needs were properly met. Staff had not had the training needed to make sure that people’s needed were fully met and that they were protected. Training needed included Health and St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 7 Safety training, adult protection training, medication training and training in working with people with dementia care needs. 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 Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 8 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 Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 9 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): 1,3, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The information provided by the service needs some expansion to make sure that people could make an informed choice. The service should only admit people it is registered for and whose needs they can meet. People were assessed prior to being offered a place at the service. EVIDENCE: Copies of the Statement and Purpose were seen and a notice confirmed that they were available in the service. One person spoken to said that they had recently been provided with a service user guide. Two relatives we surveyed said that they felt that they received adequate information about the service in order to make a decision over whether the service could meet a relative’s needs. We did find that the Statement of Purpose covered most of the required areas but did need some additional information about room sizes and St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 10 methods of consultation and more information about how it could meet the needs of people with dementia. The documentation was not fully clear over what services people may have to pay for such as transport. There was some confusion about the level of fees with the Statement of Purpose having one figure and the manager having another. This was resolved during the inspection. A sample of 3 files confirmed that the service undertook an assessment prior to a decision being made that the service could meet their needs. The assessment covered the main areas of health and personal care but could be further developed in respect of information about people social care needs and previous lifestyle particularly for those with dementia care needs. The service had put in place a letter confirming whether or not it could meet the needs of people wanting to move to the service. During this visit we found that the service had more than the registration level of people with dementia and mental health needs. It was unclear whether this was because people had developed dementia care needs since moving to the service. The service must make sure that it does not exceed the agreed numbers and make sure that the staff have the necessary skills to meet people’s needs. Should the service wish to increase the numbers for dementia care it should apply for a variation and demonstrate that staff are adequately trained and there are adequate staff on duty to meet the needs of the people living at the service. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 11 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 poor. This judgement has been made using available evidence including a visit to this service. Everyone had a care plan that outlined their needs but there were some gaps in these specifically in relation to social needs and issues relating to people with dementia care needs. People were generally having their health and personal care needs met but there were areas that could be improved. People were generally treated with respect and dignity. The service’s medication arrangements were not safeguarding people. EVIDENCE: We looked at a sample of care plans to see whether people’s health and personal care needs were identified and were being met. These showed some improvement from our last visit however we saw little evidence of the involvement in the care planning of people that lived at the service or by their relatives. All of the plans we saw except a recent admission had a photo of the person and all contained people’s personal details including details such as nearest relatives and the contact details of health professionals involved. Care St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 12 plans contained information about people’s health and personal care needs but some plans did not provide adequate information about people’s social needs including information about their previous lifestyle. This is particularly important in respect of people with dementia if staff are to support them effectively. We also felt that the service could further develop plans in relation to working with people with cognitive impairment. There was evidence that the service had plans in place in relation to people’s nutrition needs and one person who was spending a lot of time in bed was having her fluid and dietary intake monitored although the service needed to keep a better record of the amounts taken. The service had weight charts in place and had a system for recording when people where seen by a health care professional. This was however not kept accurately and although the chiropodist and an optician visited the service records of these checks for some people could not be found. We did find that not all people were receiving dental checks. Care plans showed that fall risk assessments were in place, moving and handling assessments were completed and where people were using bedrails an assessment had been completed and a discussion had taken place with a relative. We saw that care plans were being reviewed monthly. At our two previous inspections we had required the service to make sure that professional guidance over using wheelchairs without the foot rests. The service had continued to fail to do this. A health care professional reported that she felt that people’s health care needs were usually met and that the service usually sought advice about health care issues. She did feel that the service could show improvements in the way it managed pressure sore and continence care and could involve people move in their care. We found that generally people were being treated with dignity and their privacy being respected. People were well dressed and clean and well groomed. Two relatives we spoke to also confirmed that people were always well dressed and had their personal care needs met. A health professional felt that the service usually respected people’s privacy and dignity. We observed that staff knocked on bedroom doors before entering and all bedrooms, bathrooms and toilets had locks fitted. One relative stated that they felt that the service ‘cared for all residents with compassion’. We did however see on the first day that there were some areas where the service approach to people could be improved for example providing plastic beakers for drinks when they were not needed and making sure that pureed food was presented in an appetising way. By the second day glasses had been provided. One person also told us in our survey that their relative sometimes was wearing other people’s clothes. We did observe staff treating people with respect and taking time to make sure that people understood things they were saying for example St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 13 making sure people were aware of the meal choices and offering a choice of drinks. When we spoke to two staff members they were aware of how to treat people with dignity and to ensure their privacy. On the 18th October 2007 the Pharmacist Inspector visited the home to carry out a full medication management inspection in relation to regulation 13(2) of the Care Homes Regulation 2001 as part of the key inspection undertaken by the Lead Inspector on the same day. At the previous inspection the policies and procedures document for the handling of medicines was found to be not of a standard that would detail to staff how the handling of medication within the home should be carried out. The manager confirmed that the policies and procedures document had not been updated. The medication records were still poor and could not be used to evidence that medicines were being administered as prescribed. The quantities of medication were not being recorded upon receipt and any medication carried over from the previous month was not being consolidated on the new MAR charts. This meant that the home could not perform any audits to evidence that the residents were receiving their medication as their doctor wished. The handwritten entries on the MAR charts were still being written out poorly and were not being checked for accuracy by other suitably trained members of staff. Appropriate risk assessments and care plans were still not in place to ensure that medication was administered safely and correctly, for example, there was no information available to ensure that medication prescribed as “as directed” or “when required” was given correctly. Some medication found in the trolley had not been recorded on the residents MAR charts and as a consequence the home could not tell whether some of the medication had been administered or not. The home was discarding their waste medicines into a doop bin and not returning to their community pharmacist. This meant that the home had no independent check to verify that the medication had left the premises. The home was now keeping a record of the destruction but unfortunately the records did not identify the name of the resident or the quantity discarded and therefore the audit trail could not have been completed. The medication rounds were still being carried out as seen at the last inspection and therefore the same failings were identified. There did not appear to have been any attempts to change the practices to safeguard the residents. A number of the residents had been administered flu injections by nursing staff from the local doctors surgery. The home had failed to record whether the residents had given informed consent for the procedure to be carried out. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 14 It appeared that three member of the senior staff had now received training from the provider on the safe handling of medicines. With the administration process being carried out, as at the last inspection this meant that the ‘runners’ had still not received any medication training. None of the night staff had received any medication training so the day staff were administering the nighttimes medication at 9:30pm before they clocked off. This meant that if a resident wanted to take their medication later or the directions required it to be given later then there were no trained staff available to administer this medication. No competency assessments had been carried out to see if the staff were competent to carry out the administration of medicines safely. None of the staff had received any training on how to use the Monitored Dosage System (MDS) either. The lack of training and assessments still placed the residents’ health and welfare at great risk. The home had not yet acquired a Controlled Drugs cabinet but one had been put on order. The Controlled Drugs were still being stored in a small cabinet, which was located within the trolley. The home had acquired a Controlled Drugs register and had started using it on the 24th August 2007. The home was reminded of the importance of making sure that all entries made in the register were accurate. The residents’ medication was still being stored in the “surgery”. This room did not appear to have been cleaned or tidied since the last inspection. It was also discovered that a visiting Chiropodist was carrying out her procedures with in this room, which was not appropriate due to the state and size of the room and the fact that medication within the room was not locked away in cabinets. This meant that residents possibly had access to other residents’ medication and the requirement to keep medication safe and secure was not being complied with. Duplicate medicines were still found in the excess stock cabinet and by their presence had the potential to introduce administration errors. The mobile medication trolley, which was designated at the last inspection as being too small and not fit for purpose was still being used, although the inspector was informed that a bigger trolley was being transferred from another home at the weekend. Due to the lack of space on the trolley staff were still having to share certain types of medication between residents. Concerns were expressed about 20 tablets missing from a box of Co-codamol 30/500 tablets as staff may not have realised that these tablets were stronger than the normal Co-codamol, which have a strength of 8/500. Out of date medication was found and in one case the out of date medicine had been administered to a resident. The maximum and minimum temperatures of the fridge were not being recorded on a daily basis and the fridge was not being maintained at between 2 and 8°C. As a consequence the home was again asked to remove and destroy all of the insulin contained within the fridge and seek new supplies. Concerns were expressed to the manager that the insulin that was present at the last inspection was still present within the fridge and that the contents of one vial was being administered to one of the residents. The manager was asked to address this issue immediately. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides activities for people but these need to be further developed particular for people with dementia care needs. Whilst some choice of meal is provided there is scope for this to be increased to ensure that all people have a choice of a hot meal. EVIDENCE: The service’s care plans did not adequately identify people’s social history and identify the social life they wished to have. There were no preferences identified for those people that had dementia care. The service had implemented a record of the social activities that took place but this was not fully operational therefore there were adequate records to identify the social activities that people had undertaken. We did see during the inspection that the service provided some social activities. There were sessions of arts and crafts and exercise and on the first day of the inspection we observed the person coming in to do gentle physical exercise and playing skittles with a group of people. This person had brought in a dog and people were observed to enjoy this. A relative told us that an organist visited once a month. The Care Manager told us that with the increased staffing that had been agreed St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 16 they were going to use some of the time to provide activities and we saw that the service had bought some games to use. The Care Manager also reported that she was to buy some sensory items specifically for people with dementia care. We were told there was no demand for a church service and that individual people had church members coming to visit them. A hairdresser visited the service weekly. There were no activities taking place out of the service although there were some people that would be able to take part in such activities. The service had a number of visitors and the relatives we spoke to said they were made welcome. One person reported that the staff had provided them with enormous support. The service provided the main meal at lunchtime with a lighter meal at teatime. People were able to eat their meals in their bedrooms if they wished. There was a choice at breakfast with a hot meal provided at the weekend. We looked at a copy of the menus and saw that the main meal tended to be meat and vegetables or a salad followed by a hot pudding or fruit, ice cream of yoghurts. This does mean that if people did not like the hot meal they had to have the salad. We did see that everyone was offered the choice of meal and when one person requested bread with their salad this was provided. We also saw that people were provided with a choice of drinks with their meal. On the first day of our inspection the arrangements for serving meals meant that some people had finished their first course before others sitting with them had received their meal. This had improved by our second visit. We also saw that the service has bought new crockery to replace the chipped ones seen on our last inspection. The service had also bought enough cruets for each table. The service was providing a diabetic diet for some people and we did notice that the service was not always providing them with a choice to have a hot pudding. Pureed meals were provided for some people. These were not particularly appetising with all the separate foods being pureed together. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The service had an effective complaints procedure. People felt listened to and relatives were confident that any issues they raised would be addressed. Not all staff are trained in safeguarding issues and therefore do not know how to respond to any concerns in order to protect the people that live at the service. EVIDENCE: The service had a complaints procedure and was keeping a record of any complaints received. The record identified the actions taken to address complaints. The surveys we received showed that relatives were aware of how to complain and that they felt that the service responded to any concerns they raised. Several people that lived at the service stated that they were not aware of the formal complaints process but would raise any issues with care staff. They also reported to us in the surveys that they felt that the staff listened to them and acted on what they said. Two relatives we spoke to said that in their experience that the service would sort out any concerns they had. The service had not trained staffing safeguarding issues although had plans to do so. Two staff we spoke to were aware of safeguarding issues including symptoms of possible abuse and the actions they would take if they had any St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 18 concerns. The service did not look after money belonging to people that lived at the service. The service was making sure that people that worked at the service had the necessary police and POVA checks so that people were protected. Since our last visit the service had put in a procedure to make sure that any agency staff that came to work at the service had also undergone the same checks. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 19 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): 19,20,21,24,26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Whilst the service had made progress on improving the accommodation there remained some areas that had been previously identified that needed attention to provide people with an overall good, safe standard of accommodation. The service provided people with satisfactory communal and private accommodation. The service provided people with a clean and hygienic environment. EVIDENCE: The service is located in a residential area of Uttoxeter. The service is located in a period property with large communal rooms. The service has a very large rear garden that is grassed and surrounded by shrubbery. The service has a St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 20 small patio area overlooking the main garden. There is an enclosed courtyard but this is currently not accessible to people as it is overgrown and the paving is very uneven causing a potential hazard. The service had good communal sitting areas. There were 2 large lounges suitable decorated and a large dining room that was in the process of being decorated. The service had a small smoking room. The service had adequate numbers of bathrooms and toilets but these did require some upgrading. On our previous inspection we saw that the manhole covers under the carpets had caused humps in the level of the floor. This was a potential hazard to people. We were informed that this was to be dealt with during the week of the inspection. Since our last visit the service had cleaned a number of carpets and this had improved their appearance. We were shown that the service had an improvement plan to improve the environment. This included plans to decorate and refurbish 12 bedrooms, upgrade the medication room, retile the bathrooms and sort out the internal courtyard. We saw a sample of bedrooms and these were satisfactorily furnished and decorated. We saw that people were able to bring pieces of their own furniture and rooms were personalised. One bedroom we saw had been made into a bed sitting room with settee, and table and chairs. Bedrooms had TV and seating. All bedrooms were lockable. Although the service was caring for a high number of people with dementia care there were few aspects of the environment such as the use of colour, pictorial prompts or photographs that could help people to orientate themselves to the service. The service was seen to be clean and tidy. A conversation with one of the cleaning staff confirmed that they had cleaning schedules in place. People we spoke to said that they felt the service was always kept clean. Staff were able to describe good infection control procedures and confirmed that there was always plenty of gloves and aprons provided. We did notice that the service was using latex gloves, which can potentially be harmful. We looked at the kitchen and this had been cleaned since our last visit. There were arrangements to have a new floor laid. Chipped crockery had been disposed of and new bought. The dishwasher had been repaired. The service had a small laundry that was adequate to meet the laundry needs of the service. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 21 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. The service provides adequate staffing levels to meet the current number of people living at the service. Staff are provided with induction training and a high percentage of people have completed NVQ training. Staff are not trained in areas such as medication, dementia care and safeguarding and therefore do not know how to fully meet people’s needs. The service recruitment process was generally protecting people but the service must make sure that that 2 references are always obtained. EVIDENCE: Since our last inspection the service had improved its staffing levels. The manager was no longer acting as a Care staff member and therefore having to combine caring with the management tasks. This has lead to there always being 3 care staff completely devoted to caring tasks on duty throughout the day. This level of staffing was adequate for the number of people currently living in the service but would need to be reviewed if the number of people living at the service was increased. At night the service provided 2 care staff. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 22 We looked at a sample of staff files. They all provided proof of identity and written references although there was only one for reference for one staff member. All files contained POVA first checks and apart from a new staff had Criminal Records checks. The service was also checking that staff they used from agencies had been subject to the necessary checks. People we surveyed and spoke to spoke positively about the staff. Comments included ‘they really care about people’, ‘I visit 4 times a week and have complete faith and trust in all the staff’ and ‘staff have a caring attitude to residents’. We did some positive relationships between staff and people that lived there. There was a relaxed atmosphere within the service. We checked the training that staff had received and found that all staff were provided with induction training and 6 staff had NVQ level 2 training. A further 3 were due to register to do the qualification and one person was to do NVQ level 3. The service has a high proportion of people with dementia care needs and at the time of the inspection only 1 care staff had received training in working with people with dementia. 1 care staff had received training in skin care and the 3 seniors had been trained in care planning. The District Nurse reported that she had provided training in diabetes to some staff and they had shown a positive attitude to this. 5 people received training in challenging behaviour. The service had not provided staff with training in safeguarding issues. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. The care manager had the necessary qualifications and now had the supernumery time to appropriately manage and develop the service for the benefit of the people that lived there. The service had procedures to review and develop the service that took into account of the views of the people that lived there. The service had not provided staff with the necessary Health and Safety training and this could adversely affect the people that lived at the service. EVIDENCE: St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 24 The Care Manager is qualified in care and has always worked in the field of care. She had the responsibility to make sure that the service met the required standard and legislation. Since the last inspection the manager has been removed from the care roster and is employed solely as the manager of the service. This will provide her with sufficient time to ensure that the service is well managed and provide time for her to develop and improve the service. The service had a Quality Assurance system in place to review and assess the current service. This included the views of people that lived at the service and views of staff. Surveys were completed once a year. The Responsible person completed a full inspection of the service once a year and evidence was seen that this had taken place earlier in the year. This formed the basis of the service’s business plan. Staff told us that the owners had recently started to meet with them and they had found this helpful. They had been able to raise issues and had subsequently seen some changes resulting from this consultation. There was scope for the service to seek the views of professionals to feed into the quality assurance system. The service informed us that it did not look after any of the people’s money this being done either through the local authority or by people’s relatives. Any expenditure in top of the fees was invoiced to the person paying the fees. Documents relating to aspects of health and safety were looked at. The service was undertaking checks on fire equipment. The alarm was checked weekly and a fire risk assessment was in place. Emergency lighting checks were overdue with the last check being 20/6/07. The service had an evacuation plan but the service needed to identify the individual support each person would need to evacuate the service. The service had recently had an inspection by the fire authority and there was evidence that the service was acting on the recommendations made. The service’s records did not confirm that all staff had been trained in fire safety. We made an immediate requirement to make sure this happened. The training of staff in Health and Safety issues was overdue. The service’s records people needed training in first aid, food safety training and infection control. Training had however been booked to take place within the next month. All staff except one had received training in moving and handling. St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 2 2 2 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 2 St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4&5 Requirement The information provided to people wanting to move to the service and their relatives must more clearly show what the service offers including in relation to meeting the needs of people with dementia. The service must only admit people with dementia care needs up to the number it is registered for. This will make sure that the service can meet everyone’s needs. People must have a comprehensive plan in place that identifies all their needs including social needs and shows staff how to meet these needs. The manager must seek professional guidance from appropriate medical departments. In this case a professional assessment regarding the use of foot plates on wheelchairs. Previous timescales of 01/01/07 and 24/08/07 not met Timescale for action 01/12/07 2. OP1 4 17/11/07 3. OP7 15 01/12/07 4. OP8 13 1 (b), 13 3 07/11/07 St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 27 5. OP8 13(1)(b) 6. OP18 13(6) 7. OP30 18 (1ci) Arrangements must be put in place for all people to have the opportunity to have regular dental checks. This will make sure that their health and wellbeing is promoted. Staff should all have the knowledge about safeguarding issues in order to protect the people that live at the service. Training including food and hygiene training must be provided at the appropriate frequencies. Previous timescales of 01/02/07 and 24/9/07 not met. 01/12/07 01/12/07 18/11/07 8. OP30 18 (1)(c)(i) Training must be provided appropriate to the role the staff are to perform. Training in medication and working with people with dementia must be provided to make sure that the service is able to meet the needs of people that live at the service. Previous timescales of 01/02/07 and 24/9/07 not met. 22/10/07 9. OP9 13(2) 10. OP9 13 (2) Medication must be administered as prescribed and in accordance with the cautionary and advisory labels, with records kept when a prescriber has authorised a change to ensure that medication is given safely and correctly. Previous timescale of 24/08/07 not met Accurate, complete and up to date records must be kept of all medication received administered and disposed of to ensure that medication is accounted for, is available and is DS0000005003.V352248.R01.S.doc 24/11/07 24/11/07 St Mary`s Mount Version 5.2 Page 28 11. OP9 13 (2) 12. OP9 13 (2) 13. OP9 13 (2) 14. OP9 13 (2) 15. 16. OP9 OP19 13(2) 13(4)(a) given as prescribed. Previous timescale of 24/08/07 not met Appropriate information relating to medication must be kept for example in risk assessments and care plans to ensure that staff know how to use all medication including when required and as directed medication so that all medication is administered safely, correctly and as intended by the prescriber. Previous timescale of 24/08/07 not met Staff who administer medication must be trained and competent and their practice must follow written policy and procedures to ensure that residents receive their medication safely and correctly. Previous timescale of 24/08/07 not met Medication must be stored within the temperature range recommended by the manufacturer to ensure that medication does not loose potency or become contaminated. Previous timescale of 24/08/07 not met All medication must be stored securely so that only authorised persons has access to it. Previous timescale of 24/08/07 not met A Controlled Drugs cabinet must be install to meet the Misuse of Drugs (Safe Custody) regulations The responsible person shall ensure that all parts of the home to which people who use the service are so far as reasonably practicable free from hazards to their safety. This to include the raised carpet in the corridors. DS0000005003.V352248.R01.S.doc 24/11/07 24/11/07 24/11/07 24/11/07 18/01/08 01/11/07 St Mary`s Mount Version 5.2 Page 29 Previous timescale of 10/08/07 not met 17. OP38 18(1)(c)(i ) 23(4) Staff must receive the required Health and Safety training in order to make sure that people are not placed at risk. Examination of the fire records showed that staff had not received fire training and as a consequence the safety of the residents in the event of a fire was compromised. All staff must receive appropriate fire training. The support that people would need to be able to evacuate the service must be identified. This will make sure that staff have the necessary knowledge to support people. 01/12/07 18. OP38 24/10/07 19. OP38 23(4) 01/12/07 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. 6. Refer to Standard OP3 OP7 OP10 OP9 OP9 OP9 Good Practice Recommendations That the service develop its assessment to include a social history and more information about people’s previous lifestyle. That the service develop person centred planning particularly for people with dementia care needs. The service to make sure that people always wear their own clothes. It is recommended that the competency of staff administering medication be assessed at least six monthly. It is recommended that the general practitioner be asked to sign the PRN protocols. It is recommended that the staff undertake the ‘Safe Handling of Medicines’ training. DS0000005003.V352248.R01.S.doc Version 5.2 Page 30 St Mary`s Mount 7. 8. OP16 OP12 To make sure that everyone that lives at the service is provided with a copy of the complaints procedure. To ensure current records for the social care provided at the home were made available. To listen to the people who use the service and develop activities internal & external to the home. To look at providing some community activities To look at providing a greater choice of meals including for people that require a diabetic diet. To make the purred meals more appetising. To look at environmental changes to the accommodation in line with good dementia care practices. To clear and make safe the internal courtyard for people to access. To upgrade the bathrooms and toilets. To use non- latex gloves. The level of staffing must be kept under review to make sure that the service is able to meet people’s needs. 2 references must be obtained for all staff employed at the service in order that people can be protected. To consider seeking the views of professionals as part of the Quality Assurance system. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. OP12 OP15 OP15 OP19 OP19 OP19 OP30 OP27 OP29 OP33 St Mary`s Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Mount DS0000005003.V352248.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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