Inspection on 06/04/05 for St Mary`s Nursing Home

This inspection was carried out on 6th April 2005.

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

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

Other inspections for this house

St Mary`s Nursing Home 08/05/06

St Mary`s Nursing Home 03/10/05

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 Marys Nursing Home Undercliff Road East Felixstowe Suffolk IP11 7LU Lead Inspector Kevin Dally UnAnnounced 06 April 2005 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address Undercliff Road East, Felixstowe, Suffolk,IP11 7LU. 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) 01394 274547 01394 278131 None Mrs Rema Jayarajan Mrs Irene Margetts Care Home with Nursing 40 Category(ies) of Older People registration, with number of places St Marys Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th October, 2004 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 it’s 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 Marys Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report followed an unannounced inspection of St Mary’s Nursing Home; carried out over 7.5 hours on a weekday afternoon between 12.30pm and 8pm. This inspection, whilst in response to a complaint received about some aspects of the care provided, also included a routine unannounced inspection. Of the 5 areas of concern raised by the complaint, only one area around the quality of the teatime menus was upheld. The inspection found that of the 28 National Minimum Standards inspected, the home fully met 24 standards, with 4 being partially met. Overall this inspection concluded that the Home had positively dealt with any previous shortfalls, and had improved the service for its residents. During the inspection four service users, 1 relative, two staff members and the manager were spoken with, and they provided their views on the quality of the service. What the service does well: What has improved since the last inspection? All of the shortfalls from the previous inspection had been fully addressed by the Home. The Home had now replaced the worn non-slip shower surfaces within two shower areas, and provided all radiators with protector covers. This will greatly improve the facilities and make them safer for residents. There was now a maintenance programme for the Home, and scheduled work had begun. St Marys Nursing Home Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marys Nursing Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection St Marys Nursing Home Version 1.10 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 standard(s) 1,2,3,4,6 New residents had been appropriately admitted to the Home and existing residents continued to have their needs assessed by staff trained to do so. EVIDENCE: 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 a resident’s records examined, 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. One new resident spoke about their recent admission to the Home, 2 weeks ago. The Home had been recommended by a friend and so far was very happy with the care and support received. They confirmed that all their personal needs were being met. The records of another resident were examined and these clearly demonstrated that a detailed assessment of their nursing care needs had been thoroughly undertaken. St Marys Nursing Home Version 1.10 Page 9 St Marys Nursing Home Version 1.10 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 standard(s) 7,8,10 The promotion of health at the Home was taken seriously. The nursing staff and support workers regularly monitor resident’s health care needs, and ensure that proper records were maintained at all times. The staff team received training in order that they were able to meet resident’s personal care needs. EVIDENCE: On the day of the unannounced inspection, all residents, except two were up, fully dressed and located either in their private room or within the dining room, down stairs. Two residents were being nursed in their bed, and after discussion with the manager, it was identified that these two residents had specific nursing needs. One of these residents care was tracked, and a full account for the reasons for bed care had been recorded within their care plan. The plan had been reviewed each month. Additional nursing assessments were available, and these clearly identified the reasons for this care. Additionally the service user’s spouse, who visited daily, was spoken with, and who confirmed that their relative had lived at the Home for a number of years. They confirmed that their relative’s health had recently deteriorated, thus the need for bed rest. This had not always been the case. Furthermore, the relative confirmed that they had been fully consulted by the Home, about the need for bed care. St Marys Nursing Home Version 1.10 Page 11 This relative was complimentary of the care provided by the staff, and stated that staff met their relatives care needs, were always willing to help, were polite and respectful. After discussion with 3 further residents and 2 staff members, personal observation of this resident’s care, and the tracking of a service user with continence problems, the nursing practises of the Home were found to be good. Continence assessment records were found in place, and had been recently reviewed. Continence issues were also included within a service user’s care plan, and had been updated. One resident’s records examined included a wound assessment; a dependency profile, a pressure sore risk assessment, and a nutritional screening risk assessment. These assessments were found to be appropriately linked with the residents care plan and personal risk assessment. All had been reviewed each month, were signed and dated. One staff nurses records examined recorded that they had received extensive training including continence care, so were found to be appropriately trained to manage and meet the needs of the residents at the Home. St Marys Nursing Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 With staff support, residents were enabled to be involved in meaningful recreational activities, exercise choice, and make decisions about the lifestyle that they wished to pursue. Contact with relatives, friends, and family was encouraged, and there were also some limited opportunities to go into the community. Residents were provided with a good diet, however some concerns remained about the teatime menu. EVIDENCE: St Marys Nursing Home Version 1.10 Page 13 An activities programme was provided by the Home, which any resident could join, should they wish to. The activities list had been posted on the wall, with the weeks planned events. Residents were seen enjoying various activities during the afternoon, which was being run by some of the staff. One resident confirmed that there was usually an activity each day, but that they had chosen not to join the activity, on that day. Another resident confirmed that they received regular visits from a close friend each week, and that there were no restrictions placed on visiting times. Discussion with a resident confirmed that they were able to rise and settle when they so chose. This unannounced inspection was undertaken as the result of some concerns received by the Commission, one of which was around the meals provided. The complainant stated that they thought that the food was not fresh, largely packet food, and not easily edible. Further, that the Home did not provide yoghourt or ice cream, and that residents did not like the food and probably lost weight because of this. The inspection was therefore timed to cover both the lunch and tea time periods. The relief cook was on duty and the lunchtime meal was checked. The meal option was sausages or fish with fresh vegetables and potatoes. Bread and butter pudding and/ or ice cream. This meal was found to be appetising, well presented and looked and smelt good. The residents spoken with were very satisfied with the meal. The teatime meal was by contrast, not very appealing. Options included assorted sandwiches, or a salad, or a hot alternative being pitcher pie and tomatoes, and butterscotch pudding for afters. Therefore the previous weeks evening menu was more closely examined, and some additional options included soup, fried eggs, fish fingers, and beans on toast, cheesy pie. The desserts menu for the week recorded fruit and jelly, jelly, ice cream, banana, strawberry mouse, or trifle. Yoghourt was not normally provided, but ice cream was available. The evening meals were considered in need of considerable improvement. This was fully discussed with the manager and it was agreed that the Home would fully review the teatime menu, after full consultation with the residents. The manager stated that this would be raised at the next residents meeting, the following evening. St Marys Nursing Home Version 1.10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home had a complaint system in operation, and abuse procedures were appropriately in place. Residents would be confident that their complaints would be taken seriously and acted upon. EVIDENCE: The complaints procedure was provided within the Statement of Purpose and was detailed and informative. Since the last inspection the owner had updated this document to include the address and telephone number of the Commission for Social Care Inspection, which was required, should a service user wish to contact the CSCI directly. 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 one complaint and the result was that this unannounced inspection had been undertaken. Of the five elements to the complaint only one element around meals, was upheld. This is fully discussed under the heading, “daily life and social activities”. The Home had suitable Adult Protection policies and procedures in place and were 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. St Marys Nursing Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The environment was maintained and had provided adequate communal provision. The bedroom sizes and facilities provided met the minimum standards. The Home had sufficient toilets and washing facilities, and resident’s rooms were found maintained and clean. The environment was mostly safe, but one resident’s hot water tap temperature was found to be excessive and this was required to be made safe. The hygiene of the home was found to be clean and hygienic, without any unpleasant odours. EVIDENCE: St Marys Nursing Home Version 1.10 Page 16 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 service users. At this inspection four 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. One resident stated that, “My room [the residents room] is cleaned every day. I am very pleased with my room”. Three other residents spoken with also supported this view. Two shower rooms were found to have had their floor surfaces recently replaced and they had been properly cleaned. A domestic 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. Overall the Home was found to be clean and hygienic, and free from offensive odours, which confirmed the view that the Home was continually cleaned. At the previous inspection, a significant number of maintenance matters were found requiring attention, which included the need to provide a cyclical maintenance programme. Positively, at today’s inspection the Home was found to have fully addressed all previous concerns and now had a planned maintenance programme. At this inspection one resident’s hand washbasin’s hot water tap temperature was found to be excessive, and was required to be immediately reduced to within safe limits. 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 Marys Nursing Home Version 1.10 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 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) 27,29,30 Residents could expect that the Home would have good levels of appropriately trained staff on duty, and that their support and care needs would be met. EVIDENCE: The staff rota was viewed and demonstrated good levels of staff cover. This was discussed with the manager, Mrs Margett’s, and the staff on duty today for the next 24-hour period included the following. Morning duty: 1 registered nurse and 8 care staff, 3 domestics, 1 cook and a kitchen assistant, and the maintenance person. Afternoon duty: 1 registered nurse and 6 care staff. Night duty: 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. At the previous inspection concern had been raised around the number of hours that some staff worked. However 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. St Marys Nursing Home Version 1.10 Page 18 The Registered Nurses Rota, for the period of the 3rd to the 16th April 2005, recorded that four 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 3rd to the 16th April 2005, recorded that all care staff on the rota for this period worked part or full time shifts, and that weekly hours on average were around 30 to 49 hours per week. In only one case a staff member had worked up to 58 hours in one week, then 53 hours the following week. The conclusion of the inspection was that the management team continued to monitor staff hours, to ensure that they did not work excessively. Staff were noted as appropriately trained and able to undertake their respective job roles, and were able to meet the needs of the specific service user group. Four service users spoken with individually expressed their satisfaction with the staff group who they described as very patient, kind, polite and always willing to help. One staff member’s records checked evidenced that good training had been received. Further that the Home had undertaken appropriate recruitment and employment checks, which included Criminal Bureau Checks (CRB), references, identity checks and a medical declaration of health status. St Marys Nursing Home Version 1.10 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 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) 31, 33,38 The Home was appropriately managed and took account of resident’s views. The environment was mostly maintained, with the exception of one hot water tap, where the temperature was found to be excessive and was required to be reduced. 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 several 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. 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. Residents had a Home meeting scheduled for the St Marys Nursing Home Version 1.10 Page 20 following week and would be able to express their views on the meals and other issues. It was noted that the monthly owners report (Regulation 26 report) had not been received by the CSCI for at least 3 months, and 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. The inspection confirmed that the Home undertake routine and maintenance tasks to maintain a safe environment, although the hot water temperatures of the ground floor hand washbasin were found to be excessive, and were required to be reduced to safe limits. (Refer to standard 25) St Marys Nursing Home Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x 2 St Marys Nursing Home Version 1.10 Page 22 NO 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 15 Regulation 16(2i) Requirement The teatime menu must be completely reviewed to ensure that there is a varied teatime menu with acceptable “light” hot alternatives and more adequate choice of desserts. Residents views on the types of teatime meal alternatives that they would like, must be obtained, and these alternatives included in the revised teatime menu plan. Hot water tap temperatures must be maintained at around 43 degrees Celsius. The owners report had not been sent to the CSCI, which must be sent each month. Timescale for action 27/05/05 2. 15 12(2) 16(2i) 27/05/05 3. 4. 25 33 13(4a&c) 26(1,4c) 06/04/05 27/05/05 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. Refer to Standard 15 Good Practice Recommendations The Home should consider the provision of more frequent light meal and desert options for example, various yoghurts, and combinations like trifles, jelly and ice cream, Version 1.10 Page 23 St Marys Nursing Home fruit and custard, to encourage service user appetites. St Marys Nursing Home Version 1.10 Page 24 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street IPSWICH 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 Marys Nursing Home Version 1.10 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!