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Inspection on 20/04/06 for St Mary`s Residential Care Home

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

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 retains a good staff team who are loyal and treat the service users with respect and with care. Meals are managed extremely well. The staff listen to any concerns raised by the service users and relatives.

What has improved since the last inspection?

There has been improvement in the care planning and assessment processes, however there is still room for further improvement. Staff have been given the opportunity to increase their skills in care planning. Service users are given more opportunities to enhance their social and recreational needs. Two activity coordinators have been employed. A deputy manager has been appointed. More training has taken place. One room has been re decorated and new carpet laid. There are more clear lines of responsibilities especially in relation to the roles of the senior carers.

What the care home could do better:

Although there have been improvements in care planning there is still need for more improvement to ensure service users needs are being met. Improvements to the environment are needed to ensure that the service users needs are being met and that they live in a safe environment free from hazards. There still needs to be a better understanding of the appropriate checks that need to be in place for employment of staff.

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Care Home Market Place New Buckenham Norwich Norfolk NR16 2AN Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 20th April 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 DS0000061993.V292387.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 DS0000061993.V292387.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Care Home Address Market Place New Buckenham Norwich Norfolk NR16 2AN 01953 860956 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) Jasvinder Paul Singh Banga Jaishree Banga Mrs Daphne Fulcher Care Home 29 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (28) of places St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to twenty-eight (28) Older People, not falling within any other category may be accommodated. One (1) person, over the age of 65 years with dementia may be accommodated. The total number not to exceed twenty-nine (29). Date of last inspection 6th October 2005 Brief Description of the Service: St. Marys is a large house facing the village green of New Buckenham. Bedrooms are on the ground and first floors and consist of twenty-nine single bedrooms, two of which have an en suite facility. The Home has three communal rooms, a large reception area and a shaft lift is provided to aid service users to the first floor. There is a pleasant dining room with easy access for wheelchair users. Car parking and two enclosed garden areas are to the rear of the premises. A hairdresser visits the home twice a week and chiropody services are available. The Home provides newspapers and toiletries for use by the service users. The Home is a short distance away from the small market town of Attleborough. St Mary`s Residential Care Home DS0000061993.V292387.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 six hours. A tour of the premises was carried out and opportunity was taken to examine care and staff records. The Inspector spoke to a number of service users and relatives who were visiting at the time of inspection. The Inspector spent some time observing staff working with the service users. The manager was not present for the inspection, however a newly appointed deputy manager was. What the service does well: What has improved since the last inspection? There has been improvement in the care planning and assessment processes, however there is still room for further improvement. Staff have been given the opportunity to increase their skills in care planning. Service users are given more opportunities to enhance their social and recreational needs. Two activity coordinators have been employed. A deputy manager has been appointed. More training has taken place. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 6 One room has been re decorated and new carpet laid. There are more clear lines of responsibilities especially in relation to the roles of the senior carers. 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 DS0000061993.V292387.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 DS0000061993.V292387.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. The overall quality outcome for this standard is adequate. The admission process can be improved. EVIDENCE: Care notes for two new admissions revealed that there was a lack of pre admission assessment and therefore it was difficult to assess whether these service user’s needs could have been met. One service user who was admitted at the beginning of March had no record of where they were admitted from or what their needs might be. It is therefore required that all prospective service users are assessed prior to admission and records kept of this activity. St Mary`s Residential Care Home DS0000061993.V292387.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, 8,9. The overall quality outcome for these standards is adequate. The care plans still do not contain enough detailed guidance to staff about to how to meet the service user’s needs; however there has been some improvement in this activity. The service user’s health care needs are not being fully met. The system for administering medication is managed well. EVIDENCE: The Inspector looked at five care plans. These indicated that there had been improvement in the care planning process; but some of these had not been updated, some had not got risk assessments in place with regard to those at risk of developing pressure sores and risk of falling. For example, the daily notes for one service user stated that they had been found on the floor, but there were no details about this with regard to care planning. This same service user had had diarrhoea, however there were no St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 10 care notes to guide staff as to how to meet the needs of this service user and also to reflect infection control. Another two service user’s care plans show adequate guidance to staff to enable them to meet the needs of this person and also showed that there was continued evaluation of care on a monthly basis. Another service user’s notes indicated that they suffered from seizures; however there were no care plans in place for this. It is disappointing to see that the requirement for the care plans to be improved by 23 October 2005 and a requirement is repeated within this report. It must be noted however that some care plans showed vast improvement and it is required that all staff ensure that there is appropriate documentation in place. The Inspector looked at the medication system that is in use. A random check was made of the MAR charts with particular reference to care tracking. It was noted that there was appropriate recording in place and continual evidence of auditing the medication. The MAR charts tallied with that medication, which was left in stock and the charts, were found to be filled in correctly. Records were seen for all medication that had been returned to the pharmacy. St Mary`s Residential Care Home DS0000061993.V292387.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): 12,15. The overall quality outcome for these standards is good. There has been improvement in the range of social and recreational activities offered to the service users. Meals are managed well. EVIDENCE: Discussion with the deputy manager and staff revealed that there has been an increase in the activities on offer to the service users, activity programmes were examined and a visual record of events was seen. Some of the service users felt that they would like to be offered more activities, however the Inspector believes that these remarks reflect that the programme of activities has only just been initiated. Two carers have been given responsibility for coordinating the activity programme. One service user felt that there were enough activities being offered and stated that she did not join in because she preferred not to and was given the choice. The Inspector took the opportunity to examine the menus and the general consensus from all those service users spoken with was that the food was very St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 12 good and that they were offered many choices. The menus appeared to be nutritious and well balanced. The Inspector was able to monitor food being served and how the staff managed those service users who needed assistance with feeding. The staff were seen to talk kindly to the service users and managed to assist them with much empathy. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 13 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. The overall quality outcome for these standards is adequate. Arrangements for dealing with complaints are satisfactory. Service users are protected from abuse. EVIDENCE: Service users and relatives spoken to indicated that they would speak with the manager or a member of staff if they had a complaint or concern. They felt that the staff always listened to them and addressed their issues. One service user commented that they “do not have to make a complaint as far too happy living here”. Although the inspector was unable to see training records in relation to the protection of vulnerable adults, she was made aware that training had taken place. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 14 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): 19,25,26. The overall quality outcome for these standards is adequate. There are some areas of the Home, which are still in need of improving and making safe so that the Home meets the needs of the service users. EVIDENCE: The Inspector made a tour of the home accompanied by the deputy manager. The Home was found to be clean and free from offensive odours. Some of the rooms are in need of refurbishment and look very drab. One room has been redecorated and re carpeted since the last inspection. The carpet in the upstairs corridor needs replacing, it was found, to be, stuck down with tape and constitutes a hazard. When the Inspector arrived at the Home she found that the front door had been locked and the key hidden; an immediate requirement is made within this report to ensure the safety of service users especially in the event of a fire. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 15 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): 29,30. The overall quality outcome for these standards is adequate. Service users are not protected fully by the Home’s recruitment policies and practices. Training for staff has improved. Record keeping needs to be improved to ensure there is documentary evidence of induction and subjects covered. EVIDENCE: The Inspector examined staff recruitment documentation and training records. Discussion with staff and the examination of records led the Inspector to believe that the staff had received much more support than that of late. The records indicated training has been received by many of the staff members and was confirmed by them when asked. It was noted however that some new members of staff had no records of induction having taken place. It was also established after discussion with staff and inspection of training records that training had taken place with regard to care planning, this was also made evident on examination of care plans and the improvement that had taken place. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 16 The Inspector looked at recruitment records for four staff members; she found that one member only one reference had been obtained, Two members had a CRB in place but no POVA check had been done. One member of staff had no checks in place. It is disappointing to see that the requirement for all staff to have appropriate checks in place before employment has not been met and an immediate requirement is made within this report to ensure that all staff have checks carried out before employment commences. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 17 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): 31,33,38. The overall quality outcome for these standards is adequate. Overall management of the home has improved and staff have clear and defined roles within the Home. Some practices still do not promote or safeguard the welfare of the service users. EVIDENCE: Discussion with staff members and the deputy manager leads the Inspector to believe that the Home is better managed and that there are clearer lines of leadership. The appointment of a deputy manager has helped towards this with the greater sharing of knowledge and records being made available for inspection purposes. Those staff spoken with said that they felt that they St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 18 were much better supported in their roles and had a better understanding of their roles and the part they played within the Home. The duty rosters indicated that the deputy mostly deputises when the manager is off and the deputy although only having been post for a few weeks stated that the system was working well and that she was being encouraged to attend courses in management. Although the Inspector was unable to see the manager’s job description she was advised by the deputy that their was one now in place. Those service users and relatives spoken with commented that they felt that the home was now managed well. The Inspector certainly noticed during her observations that the staff seemed to be very much more cohesive and less fragmented. All the service users and relatives spoken with expressed satisfaction in the care that was given in the Home and that they also felt happy with the medical care they were receiving. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 19 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x x x x 2 St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? 13 (6) 13 (6) 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 OP7 Regulation 15 Requirement The registered person shall ensure that the service user has a written plan of care as to how his needs in respect of his health and welfare are to be met and keep the plan under review. The registered person shall not employ a person to work at the care home unless subject to paragraph (6) he has obtained in respect of that person information and documents specified in (1) paragraphs 1-7 of Schedule 2 It is required that all prospective service users are assessed before admission to the home. It is required that proper provision is made for the health and welfare of the service users. It is required that all parts of the home to which service users have access are so far reasonably practicable free from hazards to their safety and that DS0000061993.V292387.R01.S.doc Timescale for action 20/04/06 2. OP29 19 (1) (b) 20/04/06 3. OP3 14 (1) (a) 20/04/06 4. OP8 12 (1) (a) 20/04/06 5. OP19 13 (4) (a) 20/04/06 St Mary`s Residential Care Home Version 5.1 Page 21 the exit door is not kept locked and the key hidden. 6 OP30 18 (1) © It is required that all new staff are given appropriate induction and records made of this activity. It is required that the home establishes and maintains a system for reviewing and improving care. It is required that the carpet be replaced in the upstairs corridor, and in the meantime made safe. 20/04/06 7 OP33 24 (1) (a) (b) 13 (4) (a) 20/04/06 8 OP19 20/08/06 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 OP19 Good Practice Recommendations It is recommended that consideration be given to further improving the décor and furnishing of the home. St Mary`s Residential Care Home DS0000061993.V292387.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Residential Care Home DS0000061993.V292387.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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