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Inspection on 10/02/06 for St Mary`s Nursing Home Hull

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

This inspection was carried out on 10th February 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.

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 experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Residents are provided with a warm, safe and comfortable environment that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The staff and manager are extremely professional about their care duties and work hard to make sure the paperwork at the home is well written and up to date. This has helped the home exceed the minimum standards in a number of areas and feedback from the residents and visitors is very positive about the home and its service. One individual said `this is one of the best nursing homes in Hull and it would be hard to find a more dedicated team of staff`.

What has improved since the last inspection?

The home continues to make sure that the service and care given to the residents is specific to their needs and meets their expectations. Attention to detail is an important part of the philosophy of the home and has helped the service exceed the minimum requirements of eleven out of the twenty-four standards assessed in the past twelve months and achieve in full all of the key standards except one.

What the care home could do better:

Medication recording needs to be improved to ensure all signatures are in place for medications received, so that there is no mishandling of medication and the residents health is looked after.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home Hull 344 Chanterlands Avenue Kingston Upon Hull East Yorkshire HU5 4DT Lead Inspector Eileen Engelmann Unannounced Inspection 10th February 2006 09:30 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 Marys Nursing Home Hull DS0000000954.V264076.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 Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Hull Address 344 Chanterlands Avenue Kingston Upon Hull East Yorkshire HU5 4DT 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) 01482 348158 01482 348158 Private Medicare Limited Mrs Karen Lesley Hey Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (48), Terminally ill (48) of places St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration includes eight stroke rehabilitation patients and two intermediate care. 14th September 2005 Date of last inspection Brief Description of the Service: St Marys Nursing Home is a single storey, purpose-built home, situated in its own extensive grounds in a residential area of west Hull. There are a variety of local community facilities close to hand. The home offers ample parking and a bus stop is very close to the home.The home offers long term care with nursing to a maximum of 48 older people of either gender. There are also two intermediate care beds and eight stroke rehabilitation beds which people occupy for relatively short stays. There is a rehabilitation kitchen for these individuals to help them to regain daily living skills before moving home.Accommodation is offered in 30 single bedrooms and nine double rooms all on one level. The home has pleasant wheelchair-friendly grounds for the enjoyment of the service users. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the deputy manager (Polly Irving) and the training officer (Lynn Wilson), staff, visitors and residents of St. Mary’s Nursing Home. The inspection took 2.5 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. A number of the residents and visitors were spoken to in an informal manner; their comments have been included in this report. All key standards have been looked at over the last year and information about these standards and their outcomes is written in the report for 14th September 2005 and this one. What the service does well: What has improved since the last inspection? The home continues to make sure that the service and care given to the residents is specific to their needs and meets their expectations. Attention to detail is an important part of the philosophy of the home and has helped the service exceed the minimum requirements of eleven out of the twenty-four standards assessed in the past twelve months and achieve in full all of the key standards except one. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 6 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 Marys Nursing Home Hull DS0000000954.V264076.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 Marys Nursing Home Hull DS0000000954.V264076.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): 3 All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: The home continues to meet the criteria of standard 3. Each resident has their own individual file and those looked at had a full needs assessment completed within them. The homes needs assessment for selffunding individuals is very comprehensive and includes risk assessments as part of the information gathering process. Discussion with the deputy manager indicated she or the manager carries out a needs based assessment on all residents prior to admission, except the stroke rehabilitation and intermediate care individuals, who have the assessment completed by the specialist community care team. Those residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals, and this was found to be accurately documented within their care plans. Residents at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the Health Authority, to determine the level of nursing input required by each individual. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 9 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 and 9 The home continues to meet the criteria of standard 3. Each resident has their own individual file and those looked at had a full needs assessment completed within them. The homes needs assessment for selffunding individuals is very comprehensive and includes risk assessments as part of the information gathering process. Discussion with the deputy manager indicated she or the manager carries out a needs based assessment on all residents prior to admission, except the stroke rehabilitation and intermediate care individuals, who have the assessment completed by the specialist community care team. Those residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals, and this was found to be accurately documented within their care plans. Residents at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the Health Authority, to determine the level of nursing input required by each individual. EVIDENCE: The home continues to produce and keep clear and well-written care plans for the residents. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 10 Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. Two of the plans looked at were for fairly new residents and these have been evaluated on a monthly basis. Any changes to the care being given is documented and implemented by the staff. The care plans are well written and include detailed information about the needs and expectations of the residents and the care being given on a daily basis. Risk assessments around daily activities of living have been carried out and are recorded, where appropriate, within the individual resident’s plan. The home has taken on board the recent changes to legislation, around the way that Nursing Homes must dispose of unwanted medication. They have made arrangements to safely dispose of medication through a licensed waste disposal company and have received the necessary paperwork and equipment from this company. The medication policy and procedure must be updated to include the above information/practices for the disposal of medication. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. Several of the residents spoken to prefer to have staff administer their medication and are happy with the way this is carried out. Examination of the medication records showed up two areas that need to improve. These include ∗Staff are not always signing medication received from the pharmacy into the system. ∗Transcribed (handwritten onto the sheet) medication did not have the quantities received written down or two signatures from the staff to indicate that they had both checked the information recorded was the same as that on the pharmacy label of the box or bottle received. The inspector discussed with the deputy manager the need to audit the medications on a regular basis to ensure the records are being kept accurately, and the stock balance is correct. The above issues were noted at the last inspection and practices must move forward and improve to protect the residents from risk of harm. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 11 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): 14 The home promotes the residents right to exercise choice and control over their lives and offers information and contact details so they or their families can contact external agents, who will act in their interests. EVIDENCE: The residents spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. The deputy manager said she is aware of the advocacy groups in the community that residents can access, and the contact information is on display within the home and recorded in the Service User Guide. All the residents said that the home encouraged them to bring in small items of furniture and personal possessions to decorate their bedrooms. Discussion with the residents showed that they were aware of their care plans and were able to input to them and access them through their key workers. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 12 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): The home has a satisfactory complaints system with evidence that residents’ views are listened to and acted upon. Staff and residents are confident about reporting any concerns and the manager acts quickly on any issues raised. EVIDENCE: The complaints records show that there have been no formal complaints made since the last inspection and the deputy manager told the inspector that the staff deal with any niggles or grumbles on a daily basis. The home has a complaints policy and procedure that is found within the statement of purpose and service user guide. It is also on display within the home. The residents showed a clear understanding about how to make their views and opinions heard and said ‘the manager comes round every day to see us and will discuss any problems at this time. She will take immediate action, if needed, to resolve any issues brought to her attention’. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 13 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 Continuous investment in the home has created a comfortable, safe and pleasant environment for those living there and visiting. EVIDENCE: There is an ongoing programme of routine maintenance and renewal in place at the home. Since the last inspection the kitchen, bedrooms and corridors have been redecorated, two bedrooms have received new carpets and other rooms have had new curtains fitted. The home has also purchased another electric hoist. All areas of the home were seen to be clean, comfortable and odour free St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 14 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 Sufficient staff are employed to ensure there is a good match of well-qualified staff offering consistency of care within the home EVIDENCE: The home continues to employ sufficient staff to meet the needs of the residents. Inspection of the rota indicated that on average the home is working with four nurses and ten care assistants from 8am to 1pm, two nurses and eight care assistants from 1pm to 4pm, two nurses and five care assistants from 4pm to 9pm and one nurse and four care assistants from 9pm to 8am. Residents and relatives spoken to are very happy with the amount of staff on duty and said ‘they are always helpful and available to see to anything you need doing and nothing is too much bother’. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 15 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 and 35 The management of the home is satisfactory overall, and suitable accounting and financial systems are in place to protect and safeguard the interests of the residents. EVIDENCE: The registered manager of the home is a qualified nurse with many years of experience caring for individuals with complex nursing needs. She has been the manager of the home for a number of years and holds an up to date registration with the Nursing and Midwifery Council (NMC) and has achieved suitable management qualifications. The manager keeps her clinical skills up to date by undertaking regular training and development sessions with recognised Healthcare Professionals and Organisations. Checks of the financial records for the residents’ personal allowances showed that the home keeps written account sheets for each individual and receipts St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 16 are available for all transactions undertaken. When personal monies accumulate past the amount the home is able to keep in the home, individuals either put the surplus money into their own bank account or, where this is not possible, the excess monies are past to the safe keeping of the Provider. This is a very rare occurrence and is clearly documented onto the individual’s account sheet, and individuals have access to their monies as and when requested. The manager should ensure that information about the safe keeping of excess pocket money is documented into the service user guide. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 17 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 X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 17 Requirement Accurate records must be kept of all medications,recieved administrated and leaving the home or disposed of, to ensure there is no mishandling (given timescale of 12/12/05 was not met). Timescale for action 01/05/06 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 OP9 OP9 OP35 Good Practice Recommendations The medication policy and procedure should be updated to include the new legislation and practices for the disposal of medication. The manager should audit the medication system on a regular basis to ensure the records are being kept accurately, and the stock balance is correct The manager should ensure that information about the safe keeping of excess pocket money is documented into the service user guide. St Marys Nursing Home Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Hull DS0000000954.V264076.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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