Inspection on 03/10/05 for St Mary`s Nursing Home

This inspection was carried out on 3rd October 2005.

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 Nursing Home 08/05/06

St Mary`s Nursing Home 06/04/05

St Mary`s Nursing Home 11/10/04

St Mary`s Nursing Home 12/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Nursing Home Undercliff Road East Felixstowe Suffolk IP11 7LU Lead Inspector Kevin Dally Announced Inspection 3rd October 2005 09:45 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 DS0000024500.V256092.R01.S.doc Version 5.0 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 DS0000024500.V256092.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Mary`s Nursing Home Address Undercliff Road East Felixstowe Suffolk IP11 7LU 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) 01394 274547 01394 278131 Mrs Rema Jayarajan Mrs Lalitha Samuel, Mrs Shereen Jesudason Mrs Irene Geok Choo Margetts Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Up to a maximum of 5 places may be used to provide respite care to persons aged between 55 and 65 years of age. 6th April 2005 Date of last inspection Brief Description of the Service: St Mary’s is a privately owned care home providing care with nursing for a total of 40 older people. The accommodation is in a large, extended house set in its own gardens overlooking the sea in Felixstowe. There are 28 single bedrooms, and 6 double bedrooms, most with en suite toilet facilities. St Mary’s is close to the town centre of Felixstowe and the beach, and amenities are accessible to more mobile residents. Rail and bus services are available from the town centre to Ipswich. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report followed an announced inspection of St Mary’s Nursing Home, which was carried out over 8.0 hours on a weekday between 9.45am and 5.45pm. Mrs Margetts, the manager was present for the duration of the inspection and contributed fully to this process. The focus of this inspection concentrated on the continence practises of the home, care planning and nursing assessments. Meals provided were checked and the environment was assessed. During the inspection six-service users, 2 relatives, two staff members and the manager were spoken with, and they provided their views on the service provided. Comment cards were received from 13 service users, and 14 relatives. The inspection found that of the 33 National Minimum Standards inspected, the home fully met 26 standards, with 7 being partially met. What the service does well: What has improved since the last inspection? What they could do better: While it was noted that the home continued to provide a good standard of nursing care for its residents, of concern was an unexplained bruise noted to one individual. This was required to be investigated, and the home required to ensure that any similar situations in the future, are closely monitored. One hot water tap temperature was found to be excessive, and was required to be St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 6 immediately reduced. It was recommended that the home undertake regular monitoring of hot water tap temperatures, to ensure that they are regularly maintained. One fire door was found partly obstructed by a wheelchair, and which may have compromised the homes fire safety. This was required to be immediately resolved, and excess wheelchairs appropriately stored. The laundry door was found bolted open and further advice was required to determine if this was a fire door. Maintenance issues requiring attention included the repairing or replacement of the shower and bathroom floors. Further the owner must provide a monthly regulation 26 report for the CSCI, as part of its quality monitoring processes. A record of any accidents/injuries must be maintained within the accident book. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 DS0000024500.V256092.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People can expect that they will receive informative and helpful information about the service provided, and that their care needs will be appropriately assessed. EVIDENCE: St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 9 The home had a Statement of Purpose and Service User Guide, which described for residents the various services that the home could offer. Residents would be offered a copy of their contract of Terms and Conditions with the home, and 3 resident’s records checked included this document. Prospective residents and their relatives are encouraged to visit the home before accepting a placement, and the manager would undertake a needs assessment, which allowed the home to assess the potential service users needs and suitability of the placement. Three residents records checked contained a brief assessment of 14 areas of possible service user need. This was completed by the manager, and who would use this information to develop new care plans. Further, appropriate risk assessments, nutritional information and guidance around pressure are care, had also been provided. One resident’s records contained a very detailed assessment called the “Gloucester patient profile” which had been provided by the local hospital. A group of service users and relatives spoken with confirmed that residents personal needs were being met by the staff group. One relative, who regularly visited the home stated that they had “no concerns” about the care provided, and which they believed was “really good”. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, The promotion of health care was encouraged by the home therefore residents could expect basic planned nursing care. Resident’s health care needs were mostly well monitored, but could not always be expected. People could expect that the staff team would receive training in order that they were able to meet resident’s personal care needs. People could expect medication to be properly delivered by trained staff. EVIDENCE: Three residents care records were checked and care plans where found to have been formed using the nursing assessment model by Logan and Roper. This assessed 14 areas of assessed need, and from which care plans could be developed. Three residents with various nursing care needs were tracked in order to check how the home managed their care. Nursing problems included residents who had experienced a number of falls, or who received help with insulin, or who had skin breakdown problems. In each case, the home had positively identified by way of assessment or risk assessment, each of the residents nursing care needs. This included an assessment of the risk of falls, and chocking for one person, the pressure care needs and risks for another, and the requirements of insulin for the last resident. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 11 In the records checked, nursing staff included an assessment of the risks to each resident, including the risk of skin breakdown, a nutritional risk assessment and moving and handling risk assessments. Monthly weight monitoring was very much in evidence, and in one case, advice had been sought from the Dietician. Continence needs for residents were also checked and nursing staff confirmed that 90 of residents had some form of continence issues. Residents were encouraged to remain as independent as possible, and strategies included assessment of continence needs, regular toileting and a quick response to requests for assistance, incontinence pads, and in some cases catheterisation. Bowel and skin issues were also carefully monitored, and any problems were referred to the Doctor. The required actions from staff to prevent problems developing, was clearly identified within care plans, and a daily record was maintained with progress or problems fully noted. An overall summary assessment was also maintained, for ease of reference, and to ensure that nursing problems were always monitored. The accident file was checked and this revealed that 37 accidents had occurred since April 2005. Positively, the manager now monitored the overall number of falls each month, and kept a separate record and graph of the number of falls for each person, in order that these could be closely monitored. This system had already been beneficial in identifying a number of residents who were more prone to falls, and where staff had been able to significantly reduce these. One resident was observed to have recent bruising around their right eye, which was unexplained. This had been reported by staff in their daily care records but had not been further investigated to determine the reason for this. The home was therefore immediately required to investigate this matter to try to identify how this injury may have occurred, and take appropriate action to address any issues found. Further, staff had not recorded this on the homes accident records, and which was therefore required. On the day of the inspection, most residents were up and dressed and were located in either the main downstairs day room, or their own rooms. Some more poorly residents were being nursed in their bed, in order to meet specific nursing care needs. Comment cards received from 13 residents all stated that they “felt well cared for”. Individual comments included “Its not just the care but the caring that is so outstanding here”, or “[I] feel that staff look after me”. 13 relative comment cards received all stated that they “were satisfied” with the overall care provided. Comments included, “My [relative] has not been here long but I am satisfied that [my relative] is being given tender loving care…” or “Staff are excellent” or “the whole family have been greatly impressed by the unfailing patience, kindness and gentleness shown by all the staff”. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 12 One staff nurses records examined recorded that they had received extensive training including continence care, so were found to have received appropriate training in order to manage and meet the needs of the residents at the home. The home continued to use blister packs and MAR (Medication Administration Records) sheets system for the storage and administration of medication within the home. The manager would normally order all the residents medication each 28 days using the Doctors medication re-order form. The home used several local surgeries’ according to which Doctor a resident accessed. Currently no resident self medicated. Lockable medication storage cabinets are provided for the safe storage of medication, within a locked medication room. Medication was administered by checking the resident’s medication labels, which included checks around their name, name of medication, dosage and frequency, and the start and completion dates of the medication. The deputy manager stated that only Registered Nurses are permitted to administer administration. Three residents medications were examined and were appropriately stored and administered, and medication records were being appropriately maintained. A small separate refrigerator sited within the medical room, was being used to contain medication preparations requiring cooling, including insulin, and these were being appropriately maintained. The refrigerator temperatures were found to have been appropriately maintained and recorded daily. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15, Residents can expect a lifestyle that enables them to participate in personal, social and leisure activities within the home, should they choose to do so. Relatives and friends can expect to be made welcome when visiting the home. Residents can expect to receive meals that are nutritious, balanced and meet their needs. EVIDENCE: The home provided an activities programme, which any resident could join, should they wish to. The activities list for the week had been posted on the wall in the corridor with the planned events. Residents were seen joining in with various activities during the afternoon, including cards and exercises. A group of residents spoken with confirmed that there was usually some activity each day to join in with. Examples included entertainment singers, craft days, exercises, church services and during the summer, a BBQ on the front lawn. Residents confirmed that they could receive visits from friends and family and that there were no restrictions placed on visiting times. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 14 At previous inspections concerns had been raised about the menu, specifically tea time meals. The main cook was on duty and the lunchtime meal was checked. Meals are rotated on a four week basis with daily hot menu choices. The hot meal choice for the day was beef hot pot or tomato omelette served with mashed or roast potatoes, cabbage and cauliflower. Dessert was rice pudding with jam, or ice cream and fruit slices. This meal was found to be appetising, well presented and looked and smelt good. Blended meals were available to those requiring soft diets and components were liquidised and served separately on the plate to maintain a variety of textures, flavours and colours. Some residents chose to eat in the dining room, and some preferred their meals in their own room. Care staff commenced by assisting more poorly residents to receive hot and nourishing food. Drinks were available throughout the day, and the lunchtime meal was unhurried with sufficient time given to residents to eat in comfort. The evening menu provided a satisfactory choice, and was a lighter meal. For example, sausage rolls, various sandwiches, soup, spaghetti, bread and butter, and milk jelly, fruit ice-cream or cheese crackers. Residents spoken with were satisfied with the meals, and felt that there was a good choice of alternatives, should something not suit. Residents comment cards received stated that 8 were happy with the food, 6 were happy with the food “sometimes”, and 2 were “not happy” with the food. While this was satisfactory, the manager should continue to closely monitor meals satisfaction, with residents. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 the following standard(s): 16,17,18 People can expect to have their complaints taken seriously and acted upon. Resident’s safety by appropriate training and recruitment checking can be expected. Abuse procedures where in place. EVIDENCE: The complaints procedure was provided within the Statement of Purpose and was detailed and informative, and provided the information as required by the standard including how a service user could contact the CSCI. The policy also stated that a complaint would be investigated within 28 days. The home had a complaints book but had not directly received any complaints from residents, within the last year. The CSCI had received two complaints, which had been referred to the home for investigation, and the results had been forwarded to the CSCI. In both cases the complaints had either not been upheld or were unable to be substantiated. The home had suitable Adult Protection policies and procedures in place and was aware of their obligation in the reporting of any allegations of abuse to Social Services, the police and/or the CSCI. The Home’s recruitment procedures included CRB disclosures, and references for all staff. There have been no POVA referrals to the CSCI within the last inspection year. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 the following standard(s): 19,20, 21,22,23,24,25,26 Residents can mostly expect a safely maintained environment, but not on all occasions. Residents can expect a clean, hygienic, and odour free environment. They can also expect to have the aids and equipment to meet their assessed individual needs. EVIDENCE: St Mary’s Nursing Home is a privately owned care home allowing for up to 40 service users to be accommodated. The accommodation is in a large, extended house set in it’s own gardens overlooking the sea in Felixstowe. There are three separate day rooms, a sun lounge and a dining room. There are 28 single bedrooms, 23 with en suite toilets, and 6 double bedrooms, 2 of which have en suite toilets. There are two bathrooms and three shower rooms. The main day room décor is neutral in colour and was provided with fixtures, fittings, pictures and carpets. The gardens were maintained, and accessible to residents, particularly in the warmer summer months. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 17 At this inspection five residents’ rooms were visited and were found to be clean and tidy, warm and properly maintained. Residents were enabled to bring some of their own personal furniture, if they so wished. Three residents spoken with in their rooms confirmed that these were well maintained, clean and tidy. The shower room floor on the first floor, and the bathroom floor on the ground floor had been painted, and which was now peeling off. The home was required to make good or replace this. The laundry door was found bolted open. The home was required to take advice to determine if the laundry door is identified as a fire door. If so, this door must be kept closed to avoid compromising fire safety. At the inspection the home was found to be clean and hygienic, and free from offensive odours. Liquid hand wash soap and paper towels were in evidence throughout the home. Staff spoken with confirmed that there were usually 3 cleaning staff on each day, one per floor, and that they worked very hard to maintain the home’s cleaning standards. At this inspection, one hand washbasin’s hot water tap temperature was found to be excessive, and was required to be immediately reduced to within safe limits. As this matter has been raised on a number of pervious visits, it was recommended that the home undertake regular checks, and maintain records around hot water tap temperature checks to ensure that these are being appropriately maintained at around 43 degrees Celsius. A number of wheelchairs had been stored by the main entrance stairway; one of which obstructed a self-closing fire door. These must be removed to a more appropriate storage area to ensure that the homes fire protection is not compromised. The home was found to be accessible to residents. Aids, hoists and adaptations were provided to meet residents assessed needs, and had been identified through manual handling risk assessments and needs assessments. A variety of hoist slings were readily available for staff use and these were properly maintained and stored. Grab rails are provided in the bathroom, shower and toilet areas, and bedrooms have an accessible call facility. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Residents could expect that the home would have adequate levels of nursing and care staff on duty, although certain periods during the day may be very demanding. Residents could expect that staff would receive detailed training in order that they could meet their nursing care needs, and would be properly recruited. EVIDENCE: The staff rota was checked which recorded good levels of staff cover. This was discussed with the staff group who confirmed the number of care and nursing staff on duty today, for the next 24-hour period. This included the following. Morning duty: 7am to 3pm 1 registered nurse and 8 or 7 care staff, 3 domestics, 1 cook and a kitchen assistant, and the maintenance person. Afternoon duty: 3pm to 8pm 1 registered nurse and 6 care staff. 1 assistant cook. Night duty: 8pm to 7am 1 registered nurse and 3 care staff. Further, a number of the care staff were adaptation nurses, awaiting registration with the Nursing and Midwifery Council, so were in effect, experienced nurses, but unable to practice professionally, until registered. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 19 At previous inspections concerns had been raised around the number of hours that some staff worked. A submission had been received from the owners, in which it was stated that the home fully monitors staff working conditions including the number of hours worked by its employees. Further, that that these patterns of work conform to the legal and regulatory framework governing working hours for staff, and that residents will not be adversely affected by it. The registered nurses rota, for the period of the 18th September to the 15th October 2005, recorded that five registered nurses would be working either day or night duties, over each seven day period. Rest periods had been allowed for between day and night duties, and days off each week. The care staff rota, for the period of the 18th September to the 15th October 2005, recorded that all care staff on the rota for this period worked part or full time shifts, and that weekly hours worked ranged from around 30 to 53.5 hours per week. Where staff worked over 48 hours per week, they had signed an opt agreement from the working time directive. Some staff working patterns, for example 2 long days in a row or a long day followed by a night shift were noted, and which may be exhausting for some staff. (A long day being 11.5 hours in duration). Therefore it was recommended that management continue to closely monitor this situation to ensure that staff do not work excessive hours or patters of work which may be to exhausting for them. From feedback received from residents and relatives confirmed that they found the staff group very caring and supportive of their personal care needs. Comments about staff included, “Staff are excellent” or “the whole family have been greatly impressed by the unfailing patience, kindness and gentleness shown by all the staff.” 12 of 13 comments cards received from relatives stated that they considered that there was always sufficient staff numbers on duty. 13 of 14 comment cards received from residents stated that they felt staff treated them well. One resident made no comment. The staff training programme was checked and this revealed that the home take training seriously. Nurses are provided with specialised training opportunities, which so far this year had included, training around continence issues, leg ulcers, I.V and Venepuncture training, nutrition and diet training, and foot care training. Care staff receive annual updates including fire, first aid, infection control, dementia, food handling and nutrition training. Staff records checked revealed that staff had received good training and so would be able to meet the needs of the service users group. Recruitment records checked revealed that appropriate recruitment and employment checks were in place, which included Criminal Bureau Checks (CRB), references, identity checks and a medical declaration of health status. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38 The home was appropriately managed and took account of resident’s views. The environment was mostly maintained, but may not be safe at all times. Staff had received appropriate health and safety training for the protection of residents. The owners report to the CSCI needed to be recommenced. EVIDENCE: Mrs Margetts, the registered manager, is a Registered Nurse who has had a number of years experience in the care of the elderly, and management of the home. Mrs Margetts holds an NVQ level 4 in management, as required by the standard. St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 21 From comments received from residents, relatives and staff, confirmed that the home continued to ensure that there was an open and inclusive atmosphere at the home. Quality assurance questionnaires and planned residents meetings confirmed that residents were provided with positive opportunities to feedback their views on the operation and management of the home. 8-quality assurance feedback forms checked revealed residents satisfaction with the services provided. As the owners are not present at the home on a day-to-day basis, a regulation 26 reports was required each month. It was noted that the owners report had not been received by the CSCI for the last 5 months, and this was required. Staff spoken with, and records examined, confirmed that staff receive health and safety training including moving and handling, fire training, first aid, infection control and food hygiene. Supervision records checked revealed that staff had received irregular supervision, and that this was required to be undertaken on a regular basis. This inspection confirmed that the home undertake routine and maintenance tasks to maintain a safe environment, including fire drills and records. However a number of wheelchairs had been stored by the main entrance stairway; one of which obstructed a self-closing fire door, and was required to be moved to a more appropriate storage area, to ensure that the homes fire protection was not compromised. A risk assessment was required around the laundry door being bolted open. (Refer to Standard 19) The hot water temperatures of a first floor hand washbasin was found to be excessive, and was immediately required to be reduced to safe limits. (Refer to standard 25) St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 2 2 x 2 St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 23 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 DO8 Regulation 13,4,b,c, 13,6 Requirement The home must investigate the causes of a resident’s bruising around their right eye, which was unexplained, and take appropriate action to address any issues found. Wheelchairs must be appropriately stored to avoid obstruction of a self-closing fire door. This is to ensure that the homes fire protection is not compromised. The flooring in the shower and bathroom must be made good or replaced. The home must obtain advice to determine if the laundry door is identified as a fire door. If so, this door must be kept closed to avoid compromising fire safety. Hot water tap temperature must be maintained within safe limits to prevent residents being scalded. The owners must provide a regulation 26 report each month Regular supervision must be undertaken. DS0000024500.V256092.R01.S.doc Timescale for action 03/10/05 2 OP19 13,4,a,c 23,4,c,iii 03/10/05 3 4 OP19 OP19 23(2)(b) 13,4,c, 23,4,a 01/01/05 01/11/05 5 OP25 13 (4)(a)(c) 26 18(2) 03/10/05 6 7 OP33 OP36 03/10/05 01/11/05 St Mary`s Nursing Home Version 5.0 Page 24 8 OP37 17(2), Sch 4(12)(a) Accident records must be completed after any accident 03/10/05 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 Refer to Standard OP15 OP25 Good Practice Recommendations Meals should continue to be closely monitored to ensure complete resident satisfaction. Records of all hot water tap temperatures should be undertaken to ensure that these are being appropriately monitored. Staff working hours and patterns should continue to be closely monitored to ensure that staff do not work excessive hours or patters of work which may be exhausting from them. 3 OP27 St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Nursing Home DS0000024500.V256092.R01.S.doc Version 5.0 Page 26 - 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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