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Inspection on 08/02/06 for St Mary`s Nursing Home

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

This inspection was carried out on 8th February 2006.

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

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

What the care home does well

The home has an excellent reputation within Stone and further a field. Residents spoke highly of the care they received and of the quality and caring nature of the staff. Relatives felt confident about the care their relative received and one resident stated that if she needed to receive care in the future she would come to St Mary`s. The staff were fully aware of the individual needs of the residents and provided a good service that promoted residents` dignity and privacy.

What has improved since the last inspection?

The home had addressed the requirements and recommendations from the last inspection. The home had completed a risk assessment in respect of the hot water heaters in the kitchen and had introduced procedures for the safe storage of oxygen when used in a resident` s bedroom. The home had introduced the use of gloves that did not contain latex.

What the care home could do better:

The home provided residents with a high standard of care however the home did needs to address two issues relating to Health and Safety. Firstly the home must ensure that fire alarms are always tested weekly and secondly that the procedures relating to the safe storage and handling of COSHH products ensured that the necessary data sheets were kept with the products.

CARE HOMES FOR OLDER PEOPLE St Mary`s Nursing Home Margaret Street Stone Staffordshire ST15 8EJ Lead Inspector Jane Capron Unannounced Inspection 8th February 2006 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 DS0000022372.V279509.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s Nursing Home Address Margaret Street Stone Staffordshire ST15 8EJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01785 813894 01785 819474 English Dominican Congregation (Stone) Charitable Trust Miss Elaine Hughes Care Home 54 Category(ies) of Physical disability (54), Physical disability over registration, with number 65 years of age (54), Terminally ill (3) of places St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 54 Physical Disabilities (PD) - Minimum age 60 on admission Terminally Ill (TI) - over 60 years Registration is dependent 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 7 Death & Dying. This should be achieved within the next 6 months. The category TI is for over 60 years only. One day care place as discussed Date of last inspection 19th July 2005 Brief Description of the Service: St Marys Home is a 54-bedded Care Home offering Nursing Care situated in Stone. It comprises of a three-storey purpose built building, built in early 1976. The current Proprietors The English Dominican Congregation has run the home since 1976. The home is set in a town location, however service users benefit from extensive views of large and beautiful gardens, which lead down to the fenced area alongside the canal. The home has 55 single bedrooms and one double bedroom. Some bedrooms have en-suite WC facilities. Facilities/services include a hairdressing salon, laundry services, social activities, library and religious services. There is a summerhouse in the grounds and all areas of the home have access via stairs, ramps and passenger lifts. The visiting GP 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 Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over a four-hour period. The inspection included discussions with the Managers of the home as well as several care staff. Discussions were held with a number of residents and with relatives who were visiting the home. Due to the previous excellent inspection of the home this inspection considered a small number of standards and addressed the areas where previous requirements had been made. The home had positively responded to the requirements made having addressed them. A sample of the accommodation was inspected including several of the communal rooms and a sample of the bedroom accommodation. Since the last inspection there has been no changes in the management of the home. The home has received no complaints and the Commission has made no additional visits to the home. All residents and relatives spoken to were full of praise for the home and the caring nature of the staff. Residents care needs were clearly being met. Assessments were undertaken prior to admission and all placements were made on a trial period. The home provided suitable accommodation for the residents. Bedrooms were for single occupancy and most had toilets and washbasins ensuite. The home had suitable communal areas having lounges on all floors and a small chapel on the first floor. Residents had made their bedrooms their own with a range of personal possessions including small items of furniture, photos and ornaments. The staffing levels were meeting the needs of the current residents. The home had the minimum level of two qualified staff on duty at all times. The home had a higher level of care staff on duty throughout the day than the minimum required. The home had programmes in place to provide NVQ training for staff and many staff were trained to NVQ 2 or 3. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 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): 2, 5 The home provided prospective residents and relatives with the opportunity to visit the home to ascertain whether they wanted to move there. All placements were made on a trial basis. Residents or their representatives were provided with a contract that outlined the fees and covered what the service provided and any additional costs. EVIDENCE: Prospective residents and/or their relatives were able to visit the home to look round and talk to staff. Several residents spoken to stated that they had made the choice to move to the home. Often relatives had looked at a number of homes and had decided that St Mary’s would be appropriate to meet their needs. The contract confirmed that all placements were made for a trial period. Some had chosen the home as it was important to them to have their spiritual needs met. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 9 The home or the Local authority provided residents with a contract outlining the terms and conditions of they stay at St Mary’s. All residents that funded themselves were provided with contract by the home. The examination of this showed that it clearly identified the level of fees and showed what the fees covered and any additional costs. The contract identified the room a resident was to occupy. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 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): 10,11 Residents benefited from staff that treated them with respect and dignity and who respected their privacy. The home’s staff ensured that residents following death were treated with the utmost respect and dignity and that relatives were supported and were provided with time to pay their respects. EVIDENCE: Residents stated that they found the staff to be very caring and that they respected their dignity. One relative stated that having visited her mother at the home for several years that the care was so good that if she needed care for herself she would choose St Mary’s. Staff were observed treating residents with respect and dignity. Staff spoke to residents to explain any actions they were going to take. They sought permission to undertake tasks and showed residents care and compassion. Discussions with residents and a relative confirmed that residents had their own clothes and that they were well cared for. Care staff were shown as part of their induction how residents were to be treated. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 11 The home had a good number of visitors to the home. Some relatives visited daily. Visitors were welcomed into the home and the carers and managers knew them. A number of cards and letters had been received from family members expressing their thanks for the care the home had provided for their relative. The home had procedures in place to provide care and comfort to residents who were dying and after death. The home provided support to relatives and had facilities to enable them to remain with a relative. Any wishes were discussed with the resident and relatives. The home ensured that following death residents were treated with the utmost dignity and their body prepared and any wishes were complied with. After death residents were able to remain in their rooms and then moved to the home’s Chapel. Relatives. Relatives were always provided with time to spend with their loved one before the involvement of the undertaker. The home if at all possible would always attend a resident’s funeral. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 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 the following standard(s): 12,13 The home provided residents with a lifestyle that provided them opportunities to have their social and spiritual needs met and to maintain contact with their family and friends. EVIDENCE: The home provided the residents with a number of activities but there was quite a number who were not well enough to join in. Although an adequate level was taking place some residents that were more able would benefit from more social activities. Activities included bingo, arts and crafts, gently exercises well as musical performers coming to the home. The hairdresser visited twice a week but residents were able to have their own hairdresser visiting if they wished. Residents that wished were able to go to the adjoining Roam Catholic church for Mass every day. There was also one service held in the home every week. In the summer residents went into the garden that backed onto the canal. The home had a property in Llandudno that a number of residents visited. Small groups went to stay for a few days and others went for the day. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 13 Residents said that the homes’ routines were quite flexible. They could go wherever they wanted in the home and one resident went for a walk in the garden every day. Another resident went to a local pub. Residents said they could get up when they wanted and could have drink in bed if they wanted one. Breakfast was taken in the residents’ bedrooms. Most residents who were able had their meals in the downstairs dining room but could if they wished have meals in their room. Whilst the overall provision of meals was not inspected it was noted that the pureed/ soft meal provided on the day of inspection did not look appealing and the home could consider alternative ways of presenting this diet. The home was also asked to look at the vegetarian choices offered. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: None of these standards were assessed on this inspection as the home exceeded all the required standards on the previous inspection. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 23,24 The home’s location and layout was suitable to meet the needs of the residents. The home was well maintained internally and the large gardens were well-kept and provided residents with a good facility. The residents were provided with comfortable communal facilities and with private accommodation that was both comfortable and provided them with privacy. EVIDENCE: The home was located close to the centre of Stone and adjoined St Mary’s Roman Catholic Church and convent. The home was set in large grounds that provided a place for residents to walk and sit. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 16 Bedrooms were of a suitable size and had been well personalised by the occupant and their relatives. Bedrooms were suitable furnished and decorated with matching curtains and duvets. Seating was provided. Bedrooms were fitted with locks. The home provided good communal areas. On the first and second floor there were small lounges and on the first floor there was a small chapel. On the ground floor there was a large garden room, a conservatory and a small sitting area in the entrance hall. There was a large dining room on the ground floor. The main kitchen was on the ground floor but on each floor there was a small kitchen where breakfast was made and snacks and drinks were made throughout the day. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 The residents benefited from staffing levels that were sufficient to meet their needs and from a home that had programmes in place to ensure that staff were trained and qualified. EVIDENCE: The homes staffing levels were able to meet the needs of the residents. The home had the minimum level of two qualified nurses on duty at all times. The home had no residents receiving palliative care at the time of the inspection and when the home was providing this care it would need to have a higher level of qualified staff on duty. The home had good levels of care staff on duty. During the morning there were sixteen care staff on duty and nine or ten in the afternoon. This was above the minimum level required. The home had a good level of staff qualified to NVQ level 2 or above and the home had ongoing programmes for staff to undertake the qualification. Senior care staff undertook NVQ level 3. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 18 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): 31,32,38 The residents benefit from a home that is well led and where the Christian ethos provides them with the opportunity to have their holistic needs met. Whilst the home had in most respects procedures to ensure the safety of residents the home did need to ensure that Health and Safety issues identified were addressed. EVIDENCE: The Care Manager of the home has long experience in nursing and has undertaken NVQ 4 in management. She attends additional training to keep up to date with current practices. She and the Responsible Individual work closely together to ensure that the holistic needs of the residents are met. They are well respected by staff, residents and relatives and are always available to discuss any issues and to provide support. The home ethos provides an St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 19 environment where each resident has the opportunity to have their physical, social and spiritual needs enhanced. The home had a Health and Safety policy and procedures in place. The home had developed a range of risk assessments in respect of the building including access to the garden. The home had plans in place to ensure that staff undertook the necessary mandatory training including moving and handling, fire safety and food hygiene. All staff undertook training in infection control as part of their induction training. The domestic staff had undertaken training in respect of issues of storing and handling hazardous substances and were aware of good standards in relation to cleaning. Hazardous substances were kept locked away. Data sheets were not available with the COSHH products in one of the cleaning stores. The home undertook checks in fire equipment including the fire alarm, doors and emergency lighting. Fire alarm and emergency lighting tests were being done monthly. The requirement for the testing of fire alarm tests is weekly. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 4 X X 3 3 X X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X X X X 2 St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP38 OP38 Regulation 23(4) 13(3) Requirement To ensure that the fire alarm is tested on a weekly basis. To ensure that the COSHH data sheets are kept with the products Timescale for action 09/02/06 20/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP15 OP12 Good Practice Recommendations To look at the choices provided on the vegetarian menu To look at methods of making the soft/pureed diets more appetising To consider whether additional activities could be provided for residents. St Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Stafford Office 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 Mary`s Nursing Home DS0000022372.V279509.R01.S.doc Version 5.1 Page 23 - 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. 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