Inspection on 08/05/06 for St Mary`s Nursing Home

This inspection was carried out on 8th May 2006.

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 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 03/10/05

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 Unannounced Inspection 10:00 8 & 12th May 2006 th 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.V294516.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 DS0000024500.V294516.R01.S.doc Version 5.1 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.V294516.R01.S.doc Version 5.1 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. 3rd October 2005 Date of last inspection Brief Description of the Service: St Marys is a privately owned care home, providing care with nursing for up to 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 Marys 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. The current weekly charges range from £442 to £600 per week. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. St Mary’s Nursing Home provides care for up to 40 older people, with nursing care needs. This unannounced inspection was undertaken over two days, on the 8th May and the 12th May 2006. This was a key inspection that assessed the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. This inspection focused on the outcomes for more vulnerable residents around the nursing care received and the moving and handling practises of the home. This was to review the service since the CSCI investigated a complaint in December 2005, around the care and moving and handling practices. Additionally care planning, risk assessments; accident and incident reporting and nursing assessments were checked for evidence of good record keeping and ongoing management monitoring. The meals provided were checked and the environment was assessed. Residents, relatives and staff provided additional feedback about the service provision, and how they met residents’ care needs. Comment cards were received from 13 service users, 18 relatives, and 2 staff members. Two staff members’ records, and policy documents were checked, and an environmental tour of the top floor of the home was completed. The manager, was present for both days, and contributed to the inspection process. The inspection of the medication standard was conducted simultaneously by the CSCI Pharmacist Inspector. Some requirements and recommendations were made as a result of his inspection. A copy of the separate Pharmacy Report has been submitted to the provider and is available subject to request. The inspection found that of the 31 National Minimum Standards inspected, the home fully met 23 standards, with 8 being partially met. What the service does well: Since the last inspection, the home has worked very hard to review and improve its services. This inspection revealed the quality of the nursing and medical care provided to residents was to good standards. This was confirmed by the positive feedback received from residents, relatives and staff. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 6 An audit conducted of the nursing care of more vulnerable residents revealed the home closely monitored resident’s falls or bruising, which demonstrated attention to detail. Care plans recorded essential care requirements, while risk assessments assessed residents’ possible vulnerability against any identified problems. Moving and handling practices were found to be of an acceptable standard and staff moving and handling training had been updated. Since the last inspection the home has reviewed its written processes to reduce unnecessary paperwork, but improve essential recording data. Staffing levels, staff training and skills were found to be adequate, although relatives thought more staff were needed. Residents and relatives commented that staff were kind, respectful and very caring towards residents, who assisted them with their nursing care and support needs. The home was found to be clean, warm and mostly maintained, with the exception of one fire door opener, which was not working. Staff employment and recruitment records were checked and were mostly in place, and staff training and supervision continued. The management of the home continued to be responsive to the needs of residents. What has improved since the last inspection? What they could do better: While it was noted the home provided a good level of nursing care for its residents, of concern was the adequacy of the current activity and leisure programme, which must be reviewed. Resident’s choices must be respected and followed, and one resident’s records must be updated to include recent bruising. The fire Dorguard for one room was not working and was wedged open. This was required to be immediately removed and repaired. Fire evacuation plans must be developed for any vulnerable resident, particularly those on the top floor. Wheelchair harnesses must be repaired or removed based on residents’ needs. One staff member’s records must include 2 suitable references to evidence their suitability to work with vulnerable adults. Concerns were also identified around the number of hours some staff worked each week. Management should urgently review this situation to ensure that staff do not work excessive hours or patters of work which may be to exhausting for them and effect the care they provide. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 7 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.V294516.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 their care needs will be appropriately assessed. EVIDENCE: The home’s Statement of Purpose and Service User Guide described for residents the various services the home could offer. Residents were offered a copy of their contract of Terms and Conditions with the home, and 2 residents’ records checked included this document. Prospective residents and their relatives are encouraged to visit the home before accepting a placement. The manager undertakes a needs assessment, which enables the home to assess the potential service user’s needs and suitability of the placement. Two residents’ records checked contained a brief assessment of 14 areas of service user need, which had been used to develop these residents’ care plans. Appropriate risk assessments, continence assessments, nutritional information and guidance around pressure area care, had also been provided. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 10 Service users and relatives spoken with confirmed that residents’ personal care needs were being met by the home. One relative spoken with stated they thought the home offered “genuine care”. Eighteen relative feedback forms received confirmed that overall they were satisfied with the care provided. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The promotion of health care was encouraged by the home therefore residents could expect planned nursing care. Residents’ health care needs would be monitored. People could expect the staff team would receive training in order to meet residents’ personal care needs. Medication practises may not always follow recommended national guidelines. EVIDENCE: This inspection focused on the outcomes for more vulnerable residents at the home around the nursing care received and the moving and handling practises of the home. Nine residents were tracked to check how the home managed their care and included residents who had experienced falls, problems with moving and handling or recent bruising. In all but one case, the home had positively identified by way of assessment or risk assessment, each of the resident’s nursing care needs. This included an assessment of the risk of falls, moving and handling risk assessments, or the use of body charts to record bruising. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 12 Three service users were personally spoken with about their moving and handling needs including assistance with hoisting. These residents confirmed that when hoisted “staff were very careful” and “I am always hoisted, and feel confident with lifts by staff”. Two residents were observed while staff assisted them with manual handling, and this included the correct use of lifting belts or the hoist. Positively, since the last inspection, chairs within the day rooms had been moved to provide more space to the sides, allowing for improved access for staff, during moving and handling procedures. All staff had received moving and handling training at least within the last 18 months, and more training was due shortly. Feedback received from staff suggested that it would be helpful if extra hoists or lifting belts were made available. The home’s records identified there had been 74 falls in the last 12-month period. The home’s monitoring procedures were checked and revealed the manager closely monitored falls on a monthly basis. This included a record of which resident had fallen, and the time of day these occurred. This provided valuable information in order to reduce or prevent similar occurrences. Risk assessments also provided an opportunity to review any problems, including the possible causes of a fall or bruising. Where unexplained problems were identified these could be more closely reviewed. Two residents’ care records were checked and their identified nursing problems were highlighted, in addition to continence and pressure area assessments, nutritional assessments, dependency profiles, falls risk assessments and moving and handling risk assessments. Monthly weight monitoring continued as per previous inspections. Although record keeping had recently been reviewed, and some unnecessary records reduced, these were found to be detailed and consistent. 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 most residents revealed they thought staff “always” or “usually” provided the care and support they needed. One stated “sometimes”. Most residents stated they always received the medical care they needed, one stated “never”, but did not further clarify. Positive comments about the care included, “My medical needs are very well taken care of”, and “The care and support is highly professional yet given with genuine affection and thoughtfulness”, and, “judging by the improvement, good care and support have been given over a twelve month period”. Alternatively 1 resident stated, “I would like more baths for example weekly”. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 13 The inspection of the medication standard was conducted simultaneously by a CSCI Pharmacist Inspector. Three further requirements and some recommendations were made as a result of their inspection. A copy of the separate Pharmacy Report has been submitted to the provider and is available subject to request. Comment cards received confirmed residents were mostly listened to by staff who would act on what they said. Residents confirmed they were treated with respect and dignity. One comment included “I am not easily understood by some, but staff do listen and act on what is said”. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 14 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 limited 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 meets their needs. EVIDENCE: St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 15 On the day of the unannounced inspection residents were spoken with about daily life at St Mary’s Nursing home. Residents confirmed they were able to rise in the morning when they chose, and breakfast was served in their rooms. Resident’s confirmed leisure activities were sometimes provided but these were limited. Activities included visiting musicians, meetings, exercises, card games and television. Hairdressing was available which also provided a social event and an opportunity to meet with friends within the home. A summer fete was planned for July, and the well-maintained garden could be used throughout the summer months. Residents’ friends and family were welcomed by the home. Meal times were also a social opportunity to catch up on the day’s events. The home’s activities programme was checked and while there were planned events, this could be improved. Around 50 of residents’ questionnaires received stated that activities were only “sometimes” available for them to access. Comments included “I would like more activities, such as music or singing shows”, and “it’s not always easy to interest my relative in activities, but they seem more stimulated when with other residents and staff”, and “not any activities very often now I would do, only Christmas and Easter”. It was revealed the home no longer provided an activities person, which had formerly been very beneficial. Care staff now included personal activities during the afternoon between offering care. It was therefore a requirement of this inspection that the home review their activities and leisure programme to ensure that meaningful leisure activities are provided for residents. At the unannounced inspection the lunchtime meal was checked and the hot meal option was beef casserole, cabbage, potatoes, carrots and roasted parsnips. Pudding comprised of steam pudding and custard. This meal looked and smelt appetising and was well presented. The menu plan was checked and it was noted the selection and choices, particularly at teatime, had improved. Comment cards received from most residents revealed they mainly liked the meals at the home one stated “sometimes”. Comments included “The food is very good”, and “When present at mealtimes, we see my relative eating and enjoying their meals”, and “My relative says their food is full of flavour and the cook is very good here”. Alternatively 1 resident stated, “We don’t think the teas or supper is very good”. Based on resident’s comments, it was concluded that meal choices and options at the home have significantly improved over the last 12-month period. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 16 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): 16,18 People can expect to have their complaints taken seriously and acted upon. Residents’ safety, by appropriate training and recruitment checking, can be expected. Adult protection procedures were 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 received 4 concerns about the service since the last inspection in October 2005. These concerns had been appropriately followed up by the home and largely resolved. The CSCI had received 1 complaint, which was investigated by the CSCI in December 2005, after a relevant Protection of Vulnerable Adults meeting was held. The complaint was principally about the quality of the care offered and moving and handling techniques. While most aspects of the complaint were not upheld or were unable to be substantiated, a small number of requirements and recommendations were made to ensure residents’ ongoing safety. The home has made all efforts to ensure improvements were made including improved recording methods, more training for staff, and improved moving and handling practices. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 17 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 usually 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 older people 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 are well maintained, and accessible to residents, particularly in the warmer summer months. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 18 At this inspection residents’ rooms on the second floor were checked and were found to be clean and tidy, warm and mostly maintained. Residents were enabled to bring some of their own personal furniture, if they so wished. Residents spoken with confirmed their rooms were maintained, clean and tidy. On the day of the inspection cleaning staff were observed moving through various rooms and residents confirmed that staff regularly cleaned rooms. The fire Dorguard on one resident’s room was not working and was wedged open. This was compromising the fire safety of the resident and the room. The wedge was required to be immediately removed, and the Dorguard repaired. One resident located on the second floor had become bed bound and in the event of a fire, may be difficult for staff to evacuate. The home must undertake a risk assessment around this vulnerability to ensure an appropriate evacuation strategy is in place for this resident. On resident’s cabinet handle was missing and required replacement. The shower room on the second floor had controlled hot water safety measures in place. Ensuite toilets were found clean and tidy and well maintained. Samples of hot water tap temperatures taken were found to be 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 and 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. A number of wheelchairs were checked and several safety harnesses were found to be inoperable. The home was required to repair or remove these. 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 there were usually 3 cleaning staff on each day, one per floor, and they worked very hard to maintain the home. Most residents comment cards revealed that residents were very satisfied with the cleanliness of the home. Comments included “It’s very clean”, and, “It has always been the same, lovely, clean and fresh, never any different” St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 19 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): 27,28,29,30 Residents could expect the home would mainly have adequate levels of nursing and care staff on duty, although some staff may work excessive hours. Residents could expect that staff would receive detailed training in order to meet resident’s nursing care needs, and would be properly recruited. EVIDENCE: The staff rota checked recorded sufficient levels of staff cover. The number of care and nursing staff on duty today, for the next 24-hour period 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 with the Nursing and Midwifery Council. The registered nurses rota, for the period of the 30th April to the 13th May 2006, recorded five registered nurses working either day or night duties, over St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 20 each seven-day period. Rest periods had been allowed for between day and night duties, and some days off each week. The care staff rota, for the period of the 30th April to the 13th May 2006, recorded care staff on the rota for this period worked part or full time shifts, and that weekly hours worked ranged from around 17 to 56 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 followed by 4 night shifts were noted, which would be exhausting for staff. (A long day being 11.5 hours in duration). Management should urgently review this situation to ensure that staff do not work excessive hours or patterns of work, which may be too exhausting for them and impact on the care provided. Feedback received from residents and relatives confirmed they found the staff group supportive of their care needs. Comments about staff included, “There is always staff around. My relative never has to wait long if she needs help” and, “The staff are all very good. Being a nurse myself, I think everyone and everything they do are very good”. Alternatively 1 resident commented, “When staff take their break nobody is available to take residents to the toilet”. All comment cards received from residents stated the staff were available when they needed them. Ten of 18 comments cards received from relatives stated they considered there were sufficient staff numbers on duty, 7 did not. One relative did not know. The staff-training programme was checked, particularly with reference to moving and handling which revealed staff had received this training within the last 18 months. More training was planned. Nurses on the adaptation training programme received comprehensive assistance in order to register in this country. Additional training completed since January 2006 included English study, basic life support, and administration of medication, infection control, first aid, and protection of vulnerable adults training. Recruitment records checked revealed that recruitment and employment checks were in place, which included Criminal Bureau Checks (CRB), identity checks and a medical declaration of health status. One staff member’s records checked had two unsuitable references, and these must be re-applied for to ensure their suitability to work with vulnerable residents. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 21 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): 31,32,36,37,38 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. EVIDENCE: 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. The Manager holds an NVQ level 4 in management, as required by the standard. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 22 From comments received from residents, relatives and staff confirmed that the home continued to ensure there was an open and inclusive atmosphere at the home. Residents’ meeting minutes confirmed they were provided with positive opportunities for feedback to the home with views on the operation and management of the service. 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 received supervision, which was recorded. This inspection confirmed the home usually undertake routine and maintenance tasks to maintain a safe environment. The fire door guard on one resident’s room was not working and was wedged open. This was required to be immediately removed. (Refer to standard 19) A sample of hot water tap temperatures revealed that these were being maintained within safe limits. St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 23 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 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 2 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x 3 x 2 St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP7 OP8 Regulation Requirement Timescale for action 07/07/06 07/07/06 3 OP12 4 OP19 5 OP19 13(4)(a)(c One resident’s records must ) include a record of all recent bruising. 12(1)(a)( Each resident’s personal hygiene 2)(3) choices and needs must be met, including the regular provision of a bath or shower as requested. 16(2)(m) The leisure activities programme must be reviewed to ensure appropriate leisure activities are available for residents. 13(4)(a) The fire Dorguard for one room (c) was not working and was 23(4)(a) wedged open. The wedge must be immediately removed, and the Dorguard repaired. 13,4,a,c One resident located on the top 23,4,c, floor was bed bound, and in the iii event of a fire, may be difficult for staff to evacuate. The home must undertake a risk assessment around this vulnerability; to ensure an appropriate evacuation strategy is in place for this resident. 23(2)(c) On resident’s cabinet handle was missing and required replacement. DS0000024500.V294516.R01.S.doc 07/08/06 20/06/06 20/06/06 20/06/06 6 OP19 St Mary`s Nursing Home Version 5.1 Page 25 6 OP22 23(2)(c) 7 OP29 19(1)(b) (i) Sch 2(5) Wheelchair harnesses must be repaired or removed. This is an outstanding requirement from the previous inspection. One staff member’s records checked had two unsuitable references. These must be reapplied for to ensure their suitability to work with vulnerable residents. 07/07/06 07/07/06 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. Refer to Standard OP8 Good Practice Recommendations The home should ensure that it has sufficient moving and handling aids and appliances including lifting belts and hoists. The home should consider the appointment of an activities person to ensure appropriate leisure options are available for residents. Staff working hours and patterns should be closely monitored to ensure that staff do not work excessive hours or patterns of work. 2 3. OP12 OP27 St Mary`s Nursing Home DS0000024500.V294516.R01.S.doc Version 5.1 Page 26 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.V294516.R01.S.doc Version 5.1 Page 27 - 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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