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Inspection on 19/07/05 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 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

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 is exceptionally well respected in the local area of Stone. Its caring reputation and devoted staff are highly thought of. The home is able to offer service users time in their holiday home in Llandudno, Wales which is fitted with adaptations and equipment to assist those service users less mobile. Situated right on the coast, the service users and staff are able to relax together and watch the beach life and the sea views. The staff at the home are fully aware of the individual service users needs and preferences.

What has improved since the last inspection?

Policies and procedures have been updated.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home Margaret Street Stone Staffordshire ST15 8EJ Lead Inspector Joanna Wooller Announced 19 July 2005 th 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 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 Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Marys Nursing home Address Margaret Street Stone Staffordshire ST15 8EJ 01785 813894 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) English Dominican Conregation Charitable Trust Miss Elaine Hughes CRH 54 Category(ies) of PD - 54 registration, with number PD(E) - 54 of places TI - 3 St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 54 Physical Disabilities (PD) Minimum age 60 on admission Terminally ill(TI) - over 60 years Registration is dependant upon the care home having a nurse employed at the home holding the care of the dying course ENB 931 Or the university course K260 Death & Dying. This should be ahieved within the next 6 months The Category TI is for over 60 years One day care place as discussed. Date of last inspection 10 January 2005 Brief Description of the Service: St Mary’s Home is a 54-bedded Care Home offering Nursing Care situated in Stone. It comprises of a 3-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 1 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 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 care staff encourage individual service users to remain as independent as possible respecting individual personal privacy. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced visit was made on the 19th July 2005 @ 09.15hrs. Two inspectors using the National Minimum Standards for Older People as a reference undertook the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 11hrs. The registered care manager was in charge of the home accompanied by two trained nurses and sixteen care assistants. The ancillary staff on duty included; cook, two catering assistants, a team of domestic staff, two laundry staff, and two maintenance staff. Each floor had staff dedicated to kitchen duties and an administrator was in the home also. These staffing levels were assessed to meet the needs of current 53 residents in the home. 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 all the 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, quality assurance and health & safety. Since the last inspection there had been no changes to the management of the home, no complaints had been received and no additional visits had been necessitated. It was evident that individual aspects of care had been well addressed, with service users being able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written; some were based on the community care plans completed by social workers. Individual health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for service users were being upheld. No complaints, incidents or reports of abuse of any kind had been received since the last inspection, and policies and procedures seen covered these issues. The home was evidenced as fit for purpose and provided a safe environment for the service users and staff. A very homely atmosphere had been created, and the premises were clean and tidy. Adequate areas for service users were provided including; communal space, dining/activity space, bathing/toilet St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 6 facilities, and bedrooms. Services and facilities, including catering and laundry, were adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good with little staff turnover. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received regular supervision. The home appeared to be managed well by a qualified and competent manager. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures are adopted. What the service does well: What has improved since the last inspection? What they could do better: The home admit to continually trying to improve the services they offer and this is ongoing through meeting individual preferences and choices. Please contact the provider for advice of actions taken in response to this St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Individual health, personal and social cares needs had been established and were being met by staff, which individually and collectively had the necessary skills and experience. EVIDENCE: The documentation evidenced on the inspection, and partaking in a discussion with service users representatives, enabled the inspector to be assured that service users had been assessed prior to admission and they had been enabled to make a choice about the home. All service users and representatives involved had been given the opportunity to visit the home prior to choosing to stay. Several service users and their relatives spoken to had visited the home, and had a meal prior to deciding to stay, and this was documented within the care plans. Community care plans were provided by the social worker, as part of the individual needs assessment process. Service users representatives when asked confirmed that they had been fully involved and were in agreement with the assessments. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 10 The care records that were seen and a discussion with the staff evidenced for the inspector that the care staff, individually and collectively, had the necessary experience and skills to meet the assessed needs of the current service users. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The assessed health and personal care needs of service users had been well documented and were being met, with good standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines. Service users were treated with respect, privacy and dignity, during the caring process. EVIDENCE: Many service users and relatives spoken to commented positively about the care being provided to their loved ones. The service user plans and associated documentation was well written, meaningful and reflected the current condition of service users. The documentation seen on the day and with lengthy discussion with both service users and staff members evidenced that health and personal care needs were being well met. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 12 A local GP practice and a local pharmacist service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. No resident was ‘self medicating’, but locked facilities were available. During the inspection the inspectors have observed that privacy and dignity were being afforded to service users, and there was good interaction with staff. Staff were seen knocking on doors before entering. Service users told the inspector that they were treated with respect, and that the staff were very kind and good. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 to15 The home’s routines provided the service users with choice and flexibility in how and where they spent their time and provided them with the opportunity to join in activities, to have their spiritual needs met and to have contact with family and friends. The dietary needs of the service users were well attended to providing them with choice and variety. EVIDENCE: Service users had the opportunity to participate in a number of activities including bingo, OT, playing indoor bowls and doing arts and crafts. Occasionally outside entertainers including a troop of Morris dancers come to the home. Care staff take service users out into the garden and into Stone shopping. A number of service users go to the home’s holiday home in Llandudno for five days and others go for a day trip. The home provides a Catholic mass several times a week in the church and there is a video link to one of the lounges. A Church of England service is held once a month. A hairdresser visits the home twice a week. The home’s routines showed flexibility with meals being able to be taken in bedrooms, the small dining room and lounge on the upper floors or in the main dining room downstairs. Times for rising and going to bed were at the St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 14 discretion of the service users and breakfast could be taken at a time to suit themselves. The home has a high number of visitors and there were regular visitors during the inspection. Visits could take place at any reasonable time and those from a distance could stay overnight at the home. Relatives could take residents for trips out of the home whenever they wished. Local groups such as the local school visited the home several times a year. Service users were afforded choice over their daily lives, choosing where and how to spend their time. They were able to bring in small items of furniture and personal belongings into the home. The staff spoken to by the inspectors were aware of how to promote ‘choice’. The home provided a high standard of meals that offered the residents’ choice and variety. Fresh vegetables and fruit were provided on a daily basis. Service users could choose from a range of food for breakfast. The main meal was provided at lunchtime and consisted of meat and vegetables followed by a pudding that was often home baked. An alternative was always available. Tea was served at about 6pm and there was always a main meal offered as well as a range of sandwiches and cakes. Snacks such as cakes and biscuits were provided between meals and for supper. If a service user wanted something specific the home would make all attempts to provide it. The home was able to cater for special diets and provided soft and purred food. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 to 18 The robust complaints procedure was visible throughout the home. Service users were confident that their concerns were dealt with promptly. Procedures were in place to protect service users from abuse. EVIDENCE: The inspector observed the complaints process displayed throughout the home and in the Statement of Purpose and service user guide. The information included in the policy was as required. Each of the service users had been provided with a copy of the homes procedure in the event of having a complaint. Service users civic and legal rights were protected in several ways. Some service users forwarded a postal vote and others attended the polling station. The new staff received formal training via a robust induction programme and this is continued through supervision sessions. Training and general awareness of how to recognise and report any form of abuse was attended by all staff. There had been no incidents reported. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,21,22,24 and 26 The home had a high standard of accommodation both internally and externally, which provided residents with a comfortable and attractive place to live. The home provided the service users with bedroom accommodation that respected their privacy, was suitably furnished and provided then with the opportunity to make it their own. The systems in place for cleaning and the control of infection enabled residents to live in a clean and hygienic environment. EVIDENCE: The premises were suitable for its purpose. It was set close to the centre of Stone and was adjoining to St Mary’s Church and convent. The premises were homely, well maintained and welcoming throughout. Set in large attractive garden that provided seating for residents, the home had suitable communal areas having a large dining room downstairs and a small dining room on the first floor. On the first and second floor there were St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 17 small lounges and downstairs there was a garden room and a conservatory that provided ample room for sitting. On the first floor was a small chapel where service users could sit and contemplate quietly and where occasional services were held. The main kitchen was downstairs and this cooked the main meals. Each floor had a small kitchen where breakfast was prepared and where snacks and drinks were made. All bedrooms were for single occupancy and most had toilet and washbasins ensuite. Bedrooms were lockable, well furnished with matching duvets and curtains, with adequate storage space and seating. Service users had made their bedrooms their own through bringing in some of their own possessions. The home had adequate toilet and bathing facilities with each floor having an assisted baths. The first floor had a shower facility. The home had suitable equipment in place having wheelchairs available, a nurse call system and grab rails in place. The home had two vertical shaft lifts. St Marys was clean and tidy throughout. There were cleaning schedules in place. All the domestic staff had completed the relevant NVQ training. The home was aware of the expected standards for the control of infection and provided an adequate supply of gloves and aprons. It is recommended that the home use all non-latex gloves. Toilet areas had paper towels and liquid soap. Staff were aware of the need to wear different aprons for different task within the home. Procedures for effective hand washing were prominently displayed. The home had procedures in place for the effective laundry of clothing and bedding etc. Each floor had sluicing facilities. Procedures were in place for the disposal of clinical waste. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Staff skill mix and numbers was found to be in line with the previously issued notice of staffing. Service users were evidenced to be receiving high quality of care and support. All staff were evidenced as being suitably trained to carry out their duties and the homes recruitment practices were in line with the National Minimum Standards. EVIDENCE: Staffing levels appeared suitable for the dependencies of the service users. The management were aware of the need to increase staffing should this rise and this must be adhered to. Most days in the home there are three trained nurses and fifteen carers. The manager is supernumerary. Regarding recruitment, interviews were performed with the manager and one other senior member of staff. Two written references were obtained for each employee. No volunteers were employed. Induction includes lifting and handling training; fire - knowledge and instruction, meeting the service users and the aims and objectives of St Marys. The new employee worked with a mentor from day one. The management provides training at the home, this is monitored and recorded on a training matrix. The induction package is completed by all new staff and signed by a trained nurse. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 19 Over 50 of the care staff were NVQ trained and many staff were completing NVQ 3 at the present time. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 and 38 The health, safety and welfare of the service users and staff were promoted and protected as far as reasonably practicable. EVIDENCE: From observations made by the inspector, discussion with service users, and discussions with the manager and staff, it was evident that the home was being run in the interests of service users. Quality assurance was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. A check on the records and a discussion with both service users and their representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 21 Inventories of valuables and belongings brought into the home were seen recorded. A couple of health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The manager and staff spoken to confirmed that health and safety issues are given a high priority. St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 4 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION 4 4 3 3 x 2 x 3 STAFFING Standard No Score 27 4 28 x 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 4 4 x x 4 x 3 3 x 3 St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 24 Regulation 13(4c) Requirement That the home undertake a risk assessment in relation to the hot water heaters in the kitchens to ensure that they are not a hazard to residents and staff. To ensure that oxygen is suitably stored. Timescale for action 1 Day 2. 9 13(2) Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 26 Good Practice Recommendations That the home use gloves that do not contain latex St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Marys Nursing Home E51-E09 S22372 ST Marys V235078 19.07.05 Stage 4.doc Version 1.40 Page 25 - 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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