Inspection on 16/05/06 for St Mary`s Residential Care Home

This inspection was carried out on 16th 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 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 Residential Care Home 11/09/07

St Mary`s Residential Care Home 07/11/05

St Mary`s Residential Care Home 24/05/05

St Mary`s Residential Care Home 14/10/04

St Mary`s Residential Care Home 27/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings 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 Residential Care Home 14 Westbrooke Worthing West Sussex BN11 1RF Lead Inspector Mr E Mcleod Unannounced Inspection 16th May 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 Mary`s Residential Care Home DS0000014738.V291397.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 Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Care Home Address 14 Westbrooke Worthing West Sussex BN11 1RF 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) 01903 233904 Institute of our Lady of Mercy Post Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: St Mary’s Care Home is a home for older people registered to accommodate up to twenty five residents over the age of 65 years. It is a large detached property arranged on three floors situated in a quiet residential area of Worthing. Accommodation is provided in twenty-five single rooms all with en-suite and shower facilities. There is a large sized garden at the rear of the property. Facilities include a lounge, a sun lounge, a conservatory and a dining room. The service is owned by The Sisters of Mercy. There is no registered manager at present. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to follow up on outcomes from the previous inspection report. The inspector spent five and a half hours on the premises, and interviewed seven residents, three staff, and one visitor. Policies and procedures were sampled, including those for adult protection and complaints. Two sets of admission records and care records were sampled. Two sets of staff recruitment records and training records were sampled. A partial tour of the premises was made. The inspector would like to thank everyone who contributed to the inspection. What the service does well: Good information on the service provided is available to residents and prospective residents. Good arrangements are in place to ensure that a resident’s needs are being assessed before a decision is taken on admitting the resident. Care plans are in place to ensure residents’ health and care needs are being met, and these are being regularly reviewed. Meals are attractively presented, nutritious and well cooked, and are much enjoyed by residents. Specialist diets are being catered for. Residents are encouraged to be as independent as possible. Residents’ choice, dignity and privacy are respected by staff. Residents enjoy the range of social activities provided in the afternoon, and are happy with the lifestyle provided. Good communal and bedroom accommodation is being provided for residents. Furnishings and decoration are of a high standard. The home is clean and hygienic and is being well maintained. The grounds and gardens are pretty, well maintained, and wheelchair accessible. Staff are receiving supervision, support and training, and have the skills to carry out their job. Residents’ views are sought on the running of the home. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 6 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 Residential Care Home DS0000014738.V291397.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 Residential Care Home DS0000014738.V291397.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): Good information on the service provided is available to residents and prospective residents. Good arrangements are in place to ensure that a resident’s needs are being assessed before a decision is taken on admitting the resident. The outcomes for residents were assessed as good. EVIDENCE: The current scale of charges is £400 to £475 per week. The Statement of Purpose and Service User Guide seen were dated 2005/06, and will require information updated in due course such as manager and staff training. The deputy manager advised the inspector that contracts are being reviewed to include more fee information, including top-ups. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 9 Two sets of pre admission assessments were sampled, and these are ensuring that residents’ needs are being recorded and a judgement made on whether these needs can be met in the home. Pre admission information is being utilised in the plan of individual care which each resident has. Respite stays are sometimes provided by the home, but there are no facilities for intermediate care. St Mary`s Residential Care Home DS0000014738.V291397.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): Arrangements are in place to ensure residents’ care and health needs will be met. The outcomes for residents were assessed as good. EVIDENCE: Managers have advised the Commission that no residents at present have pressure sores. District nurses are attending residents where are need for this has been identified. The Commission has been advised of arrangements in place for residents to access a range of health services. Care records sampled, and discussion with residents, indicated that residents are accessing the care services they need. Care plans sampled contain information on residents’ needs and how they will be met, but could be expanded to include information on residents’ interests and how these will be supported in the home. Care plans are being regularly reviewed. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 11 Proper arrangements are in place for the administration of medicines, and staff receive training in this. St Mary`s Residential Care Home DS0000014738.V291397.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): Residents’ social and religious needs are being met. Care plans are in place to ensure residents’ health and care needs are being met. The outcomes for residents were assessed as excellent. EVIDENCE: Menus seen indicate a balanced diet is being provided, and that there are three cooked meals a day. Staff said that gluten free and diabetic meals were being prepared where there was a need for these. A lunch was observed by the inspector, which was an unhurried and sociable occasion. A choice of meals was on offer, and residents served themselves from serving plates where they could. The lunch was attractively presented, nutritious and well cooked, and was being much enjoyed by the residents. The inspector spoke with a visiting relative, who said that all the social activities being provided ensured residents were not isolated, and that staff made her feel welcome when she visited. She added that residents are encouraged to be as independent as possible, and that the home was “run for the people who live here”. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 13 Residents interviewed said their privacy was being being respected, and that the range of social activities provided in the afternoon were appreciated. Residents said that the new manager had plans for more outings to take place. There is a lovely chapel on the premises, and many residents attend the Mass held there each morning. Residents’ religious needs are being met by the home, and residents spoken to are able to maintain contact with friends, family and religious organisations they were in contact with before admission. All residents interviewed said they were happy with the lifestyle provided. St Mary`s Residential Care Home DS0000014738.V291397.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): There are arrangements for the making and recording of complaints, and responding to them. Staff training should include local adult protection procedures. The home’s adult protection procedures should be updated. The outcomes for residents were assessed as good. EVIDENCE: A complaints policy is in place, and is published in the service user guide. No complaints have been recorded since the previous inspection. 7 staff attended the Protection of Vulnerable Adults training held on 24.4.06, which includes recognising abuse but does not include local procedures in reporting and investigating abuse. The company’s adult protection procedures include a section on reporting abuse, but does not refer to the local authority as lead agency in adult protection, non-contamination of evidence, the responsibility of the provider to refer staff to the PoVA list where a need is indicated, and guidance for staff on local adult protection procedures. A whistle blowing policy is in place in the home. St Mary`s Residential Care Home DS0000014738.V291397.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): Good communal and bedroom accommodation is being provided for residents. Furnishings and decoration are of a high standard. The home is clean and hygienic and is being well maintained. The outcomes for residents are assessed as excellent. EVIDENCE: All bedrooms provided are more than 10 square metres, not including en suite facilities. All bedrooms have en suite facilities. Good toilet and bathroom facilities are being provided for residents. New flooring has been arranged for the dining room, chosen by the residents, and some bedroom redecoration has been taking place. Bedrooms and communal rooms seen were decorated and furnished to a high standard, while also being comfortable and homely. There is a chapel on the St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 16 premises which is spacious, has stained glass windows, and staff and residents are very proud of it. There are good bathroom facilities provided, and adaptations to meet the needs of the disabled have been made. There are walkways with wheelchair access all around the building, including a ramp from the car park. There is a wheelchair access toilet on ground floor, ramps on ground floor and second floor levels on the premises, and double entrance doors allowing wheelchair access at the front of the building. All areas of the home visited were clean and hygienic, and free from offensive odours. Garden and external areas are all very pretty, and well maintained. St Mary`s Residential Care Home DS0000014738.V291397.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): Staffing levels are sufficient to meet the needs of residents. Staff are receiving supervision, support and training, and have the skills to carry out their job. There are however gaps in the training undertaken by some members of staff (for example, manual handling, food hygiene, adult protection), and this could put residents at risk. Outcomes for residents were assessed as good. EVIDENCE: On the day of the inspection there were sufficient staff to ensure residents’ needs are met. There is a vacancy for a supper chef, and this is presently covered by care staff supplemental to their usual duties. Two sets of recruitment and training records were sampled. The home has a sound recruitment policy and all checks are made. There has been considerable input into staff training, and 12 staff have now completed the National Vocational Qualification (NVQ) in care to level 2 or above, or have an equivalent qualification. One member of staff is presently undertaking NVQ2. All staff are offered training relevant to their work, but the deputy manager advised that not all staff are choosing to undertake required training. Training records seen did not clearly indicate when a member of staff had last received St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 18 training in the required topics, and staff training certificate records seen were not complete. Staff are receiving recorded supervision, and staff meetings have been commenced by the new manager. Staff interviewed were happy working in the home, and residents interviewed indicated that staff observe their privacy and maintain confidentiality, treat them with respect, and everyone gets on together. Residents’ choice and independence is encouraged. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 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 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): Good arrangements for the management of the home are in place. Good arrangements for ensuring the safety of the residents and the premises are in place. Residents’ views are sought on the running of the home. The outcomes of quality assurance exercises on the service provided should be published. The outcomes for residents are assessed as excellent. EVIDENCE: The personal allowance is managed for one resident, records and receipts sampled for this were in good order. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 20 Certificates seen indicated that 10 staff had undertaken fire awareness training on 20.4.06, and 19 staff had done this training on 26.1.06. A training is being provided in July 2006 which will include use of fire equipment. The Commission has been advised of fire and other safety inspections and equipment checks which have been carried out on the premises. Risk assessments for the premises were sampled. Mr David Chadwick commenced as manager of the service on 2.05.06, and has attended meetings with staff and residents. The Commission has been advised of policies and procedures which are in place, and when these were last reviewed. A recent environmental health inspection noted that “the kitchen is hygienically operated and an excellent hazard analysis system is in place”. 15 residents had completed satisfaction questionnaires in December 2005 – these were sampled by the inspector, and indicated happiness with the service being provided. No outcomes from this have been published. An annual development plan for 2005/06 was seen, which advises areas of staff training and resident care which are to be developed. St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 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. 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 X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 4 4 4 4 4 X 4 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 4 2 X 3 3 X 3 St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 22 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. Standard OP33 Regulation 24 Requirement The results of service user surveys should be published and made available to current and prospective service users, their representatives, and other interested parties including CSCI Timescale for action 28/08/06 2. 3. OP18 OP18 13.6 13.6 4. OP30 18.1 (c) Training for staff in local adult 28/08/06 protection procedures should be provided Adult protection procedures 28/07/06 should be updated to provide more complete guidance for staff of action to be taken in the event of an adult protection incident being identified or suspected. All persons employed by the 28/07/06 registered person to work at the care home should receive training appropriate to the work they are to perform St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Mary`s Residential Care Home DS0000014738.V291397.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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