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Inspection on 16/11/06 for St Mary`s Nursing Home

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

This inspection was carried out on 16th November 2006.

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

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

What the care home does well

The home continues to have an outstanding reputation within Stone and much further a field. Service Users spoke highly of the care they received and of the quality and caring nature of the staff. Relatives spoken to at the visit felt reassured and confident about the care their relative received.The staff are fully aware of the individual needs of the Service Users and provided a good service that promoted Service Users dignity and privacy. The home offers spiritual well being which many Service Users find great comfort. The ambiance of the home is calm, welcoming and warm.

What has improved since the last inspection?

All previous requirements have been met. On going redecoration and refurbishment continues.

What the care home could do better:

The inspector was informed that the Statement of Purpose was being restyled and this will be forwarded when finalised. The home should celebrate their success more, by evidencing all they do. The care documentation was discussed with the managers at length and this is to be addressed as soon as possible. See section 2 of the report.

CARE HOMES FOR OLDER PEOPLE St Mary`s Nursing Home Margaret Street Stone Staffordshire ST15 8EJ Lead Inspector Mrs Joanna Wooller Key Unannounced Inspection 16 November 2006 09:30 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 Nursing Home DS0000022372.V318523.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 Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Nursing Home Address Margaret Street Stone Staffordshire ST15 8EJ 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) 01785 813894 01785 819474 English Dominican Congregation (Stone) Charitable Trust Miss Elaine Hughes Care Home 54 Category(ies) of Physical disability (54), Physical disability over registration, with number 65 years of age (54), Terminally ill (3) of places St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 54 Physical Disabilities (PD) - Minimum age 60 on admission One day care place as discussed Date of last inspection 8th February 2006 Brief Description of the Service: St Marys Home is a 54-bedded Care Home offering Nursing Care situated in Stone. It comprises of a three-storey purpose built building, built in early 1976. The current Proprietors The English Dominican Congregation has run the home since 1976. The home is set in a town location, however service users benefit from extensive views of large and beautiful gardens, which lead down to the fenced area alongside the canal. The home has 55 single bedrooms and one double bedroom. Some bedrooms have en-suite WC facilities. Facilities/services include a hairdressing salon, laundry services, social activities, library and religious services. There is a summerhouse in the grounds and all areas of the home have access via stairs, ramps and passenger lifts. The visiting GP’s attend weekly or as required, and access is offered to the visiting dentist and chiropodist. The main emphasis of the home is to create a Christian environment, where every opportunity is given for the enhancement of the spiritual, physical and social well being of each service user. The Nursing staff and care staff encourage all individual service users to remain as independent as possible respecting individual personal privacy. Fees – Highest £ £420 (Nursing) Lowest £328 (Residential) St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Lead Inspector carried out this Unannounced Key Inspection. The Home Manager Elaine Hughes was on duty supported by Her Deputy Manager and 12 Carers. The inspection included the following elements; A tour of the building, Observation and inspection of records relating to provision of care, Discussions with several service users, Discussions with some staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues and health & safety. The Inspector was made very welcome in the home and all assistance was given to gain the evidence required for the report. No complaints had been received by the Commission for Social Care Inspection since the last inspection. Service Users and relatives spoken to at the visit were highly complimentary about the home as were the following comments received on the many Feedback cards, which were returned. “Our family have the peace of mind that the standard of care is a special commitment” “My Mother is so fortunate to be in the care of St Mary’s Home” “I think the home is very well run and would not mind ending my days there!” “I cannot praise the management/Senior Staff enough and my Father has no complaints and is very happy. In the past when my Fathers care was difficult for the staff all the staff coped extremely well with him. I would be surprised to get this care at any other home.” “The care my Mother receives is excellent, bodily and spiritually. She is very happy and content in the home thanks to the care and thoughtfulness of all the staff.” What the service does well: The home continues to have an outstanding reputation within Stone and much further a field. Service Users spoke highly of the care they received and of the quality and caring nature of the staff. Relatives spoken to at the visit felt reassured and confident about the care their relative received. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 6 The staff are fully aware of the individual needs of the Service Users and provided a good service that promoted Service Users dignity and privacy. The home offers spiritual well being which many Service Users find great comfort. The ambiance of the home is calm, welcoming and warm. 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 Nursing Home DS0000022372.V318523.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 Nursing Home DS0000022372.V318523.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): Standard 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Service Users do have the opportunity to visit the home and assess the quality of care, facilities and overall suitability of the home prior to admission. EVIDENCE: Prospective Service Users /or their relatives were able to visit the home to look round and talk to staff. Some Service Users had chosen the home for differing reasons, as it was important to them to have their spiritual needs met, because of the homes reputation and/or had lived locally. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 9 Several Service Users spoken to stated that they had made the choice to move to the home. Often relatives had looked at a number of homes and had decided that St Mary’s would be appropriate to meet their needs. The contract confirmed that all placements were made for a trial period. The home or the Local authority provided residents with a contract outlining the terms and conditions of they stay at St Mary’s. All Service Users that funded themselves were provided with contract by the home. This clearly identified the level of fees and showed what the fees covered and any additional costs. The contract identified the room an individual was to occupy. St Mary`s Nursing Home DS0000022372.V318523.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, 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users health, personal and social care needs are identified on admission and these needs are met by the team of dedicated, well trained, professional staff. Medication policies and procedures are in place and respect and dignity is shown to Service Users at all times. EVIDENCE: The Service Users care plans did not evidence the care that is being delivered to the individuals whilst in the home. The Service Users, relatives and staff all expressed their satisfaction in the standard of care and attention given in the home and feedback forms also confirmed this. Information held in the care records was minimal and did not reflect the current condition of the Service Users health; personal or social care being received. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 11 A discussion took place with the care manager and her deputy with regard to introducing a more comprehensive system to demonstrate the care that is delivered and to recognise the professional manner in which it is carried out. There was no doubt that health, personal and social care needs are identified and met. Medication policies and procedures are adhered to and no issues were identified during the visit. The pharmacy was due to audit the system in the near future. One relative spoken to at the visit spoke very highly of the staff and there ability to carry out nursing tasks and maintain each individual Service Users privacy and dignity. Staff training and supervision ensures that privacy and dignity issues are raised and addressed correctly. The home had procedures in place to provide care and comfort to residents who were dying and after death. The home provided support to relatives and had facilities to enable them to remain in the home. Any wishes were discussed with the Service Users and relatives. The home ensured that following death Service Users were treated with the utmost dignity and their body prepared and any wishes were complied with. After death Service Users remain in their rooms and only later were they moved to the home’s Chapel. Relatives were always given sufficient time to spend with their loved one before the involvement of the undertaker. The home if at all possible would always attend a Service Users funeral. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users lifestyles in the home match their expectations and satisfy their social, cultural and religious needs. Service Users maintain contact with all friends and family as desired and they are able to exercise choice and control over their lives including meals and meal times. EVIDENCE: The home provides the Service Users with a number of activities but there was quite a number who were not well enough to join in. Although an adequate level was taking place some residents that were more able would benefit from more social activities. Activities included bingo, arts and crafts, and gentle exercises as well as musical performers coming to the home. The hairdresser visited twice a week but Service Users were able to have their own hairdresser visiting if they wished. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 13 Service Users that wished were able to go to the adjoining Roman Catholic church for Mass every day. There was also one service held in the home every week. In the summer Service Users went into the garden that backed onto the canal. The home had a property in Llandudno that a number of Service Users visited. Small groups went to stay for a few days and others went for the day. Relatives and Service Users commented that the homes’ routines were quite flexible. Service Users said they can rise and retire when they wanted and could have drink in bed if they wanted one. Breakfast was taken Service Users bedrooms. Most Service Users who were able have their meals in the downstairs dining room but could if they wished have meals in their room. The dining rooms were set out beautifully with napkins and name place cards in place. Fresh flowers were also evident and the scene was very pleasing to the eye. There was a warm and welcoming ambiance, which encouraged the Service Users to dine there in the wonderful facilities. Whilst the overall provision of meals was not inspected at the last visit it was noted that the pureed/ soft meal provided on the day of inspection did not look appealing and the home could consider alternative ways of presenting this diet. This has now been rectified and presentation has been improved. The home has also looked at the vegetarian choices offered. Menus were seen to be well balance and nutritionally sound. Many variances were evident to avoid repeat meals and boredom with the meals for the Service Users. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users and their relatives are all confident that complaints are listened to and would be acted upon as necessary. Service Users were protected form abuse. EVIDENCE: The Commission For Social Care Inspection or the home itself had received no complaints. The complaints process and procedure remains in place and visible at the home. Staff training is given relating to vulnerable adults procedures and abuse, which ensures staff are ware of the need to be vigilant for signs of abuse and they are able to report it. Individual legal rights are protected through family involvement or advocacy services. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a clean, safe and well-maintained environment. Specialist equipment is made available as required to assist individuals with mobility or independence. EVIDENCE: The environment of the home was again at this visit found to be exceptionally clean, hygienic and tidy in all areas inspected. No malodours were noted. There was evidence available for the inspector to demonstrate that the home is well maintained, with a maintenance folder of records available to demonstrate this. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 16 Well-maintained specialist equipment is evident in the home. Pressure relieving mattresses in varying forms are on each bed in the home. Individual Service Users independence is encouraged and promoted throughout the day with assistance given as required. Each service user is able to personalise their bedroom as they so wished and there was evidence that this is appreciated. Communal areas were light and airy with varying seating arrangements. The dining area remains in a designated area; dining tables have cloths, name place cards and flowers on them that most Service Users like to see. The nurse call system is in all service users areas and the cordless telephone system has proved beneficial. Outside in the grounds, garden furniture is available for warmer weather. The gardens were very well maintained and pleasing to the eye. Service Users had enjoyed short spells sitting in the shade in groups, in one to ones with staff or with visitors. The Inspector noted that the bedrooms were beginning to look a little worn and would benefit from redecoration and refurbishment which is already being addressed. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff in the home had been carefully recruited to ensure that they are competent and professional in their manner. The staff training provided is relevant and benefits the Service Users in the home. EVIDENCE: Staffing levels are monitored to ensure that the needs of the service users can be met. Staffing levels and staff competence are considered when staffing rotas are prepared. Most of the staff are first aid trained and have a food hygiene qualification. Two to three trained nurses are on duty for each shift, supported by care staff. Each trained nurse has a responsibility to a specialist subject such as continence and wound care. This link nurse role promotes current good practice within the home. Staff training is recorded and monitored. The inspector was shown evidence of appropriate training being organised, and carried out. The teaching sessions arranged were appropriate and necessary for the staff working in the care setting. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 18 A robust recruitment procedure is in place, which demonstrates the managers’ commitment to employing and developing highly qualified and professional staff. Issues of diversity are covered in the NVQ training and the staff is fully aware of ways to record individual needs and ensure they are met. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards b31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to be run and managed for the benefit of the service users. The staff are suitably supervised and they and the service users are safeguarded by the policies and procedures in home. The health, safety and welfare of service users and staff are promoted. EVIDENCE: It was evident to the Inspector whilst in the home, that the home is run in the interest of the service users. Staff and relatives confirmed that the service users wishes and choices are promoted within the home. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 20 Service users spoken to say that they felt secure in the home and they were made to feel very welcome from admission. Financial issues were all satisfactory and policies and procedures protected service users financial interests. The ethos and leadership within the home is positive and open. The manager and her team are highly thought of by service users and their relatives / representatives. Staff supervision is now in place and up to date. The health, safety and welfare of staff and service users is promoted and protected by the rigorous testing, recording and monitoring of systems within the home. The maintenance person maintains the home in a professional manner and the records seen by the inspector evidence this. St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 (1) Requirement The Registered person shall ensure that a service user plan is available for each Service User demonstrating the Service Users needs of care and how the Service Users needs are to be met. The registered person shall ensure that the Service User or a representative have seen, agreed and signed the care plan and that it is kept under review at least monthly. Timescale for action 16/01/07 2 OP8 15 (2) 16/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Mary`s Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home DS0000022372.V318523.R01.S.doc Version 5.2 Page 24 - 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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