Inspection on 20/05/08 for St Mary`s Residential Care Home

This inspection was carried out on 20th May 2008.

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 17/04/07

St Mary`s Residential Care Home 20/04/06

St Mary`s Residential Care Home 06/10/05

St Mary`s Residential Care Home 03/05/05

St Mary`s Residential Care Home 19/11/04

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 28/09/2008.

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 May 2008 05.55 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.V367139.R01.S.doc Version 5.2 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.V367139.R01.S.doc Version 5.2 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) stmarys1@btconnect.com 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.V367139.R01.S.doc Version 5.2 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 17th April 2007 Brief Description of the Service: St. Marys is a large house facing the village green in 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 new 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. Fees range from £385 to £395 weekly. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is 1star this means that the people who use the service experience adequate quality outcomes. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. We have rules that tell us how to do this and we think some of these groups are more important than others because of the way they affect people’s safety. This inspection was unannounced and took place over seven hours. During that time we spoke with five people living there, the manager and four staff members and three visitors. We got other information from the Annual Quality Assurance Assessment (AQAA) that the manager had filled in before the inspection and from records we looked at in the home. We also had some written comments from some people who live in the home. What the service does well: The service offers a homely and comfortable environment for the people who live there. There is a cohesive and caring team and service users and relatives made comments such as “everyone is going out of their way to be helpful and pleasant”, “nothing is too much trouble”, “I like being here cannot fault it”, and “the staff are wonderful”. The food is good and prepared taking into consideration the service users’ likes and dislikes. Visitors are always made welcome and the service supports the people who use the service to maintain links with their families and the wider community. People living in the home say they feel safe and they know who to talk to if they have any concerns; one service user said “I do not have any concerns, but I would go to the manager if I had”. There are good records in place to demonstrate how the service manages the health and safety of the service users and staff. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 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.V367139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have their needs assessed prior to admission to ensure that their needs are able to be met. EVIDENCE: The service has initiated a new process for the admission of prospective service users. We looked at the records for a newly admitted service user, these were good and informative; all areas of care needs had been assessed. One relative we spoke with said that they knew of the home and had an idea of what to look for; they went on to say that the staff say to her relative “treat it like home”. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The variable practice regarding the planning and delivery of care means that some service users cannot be sure that their health and personal care needs will be fully met. Improvements made in the administration and handling of medication means that service users are better protected. EVIDENCE: We arrived at 05.55hrs. We commented to the night staff that there were service users up already and the carers said “ we have got six people up and we are asked to get seven up before 7am, so we have to start at 5am to do this”. We noted that one lady was fast asleep and lolling on the dining room table, others that had been got up were either asleep in their wheelchairs or asleep St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 10 in ordinary chairs. We also noted that there were no footplates in position on the wheelchairs. We looked at the care plans for these seven service users who were up and noted that they had no entries about their wishes in relation to being got up early. One service user’s daily notes told us that he was regularly put to bed at 5.45pm, but no entry was evident on a care plan to state that this is what this service user wished. A risk assessment was in place for this service user but had not been reviewed. We looked at another service user’s records who had been got up early and noted that they were put to bed at 6.15pm. but, no care plan existed or rationale for this activity. Another service user’s daily notes indicated that they were put to bed at 5.45pm, but no care was in place to suggest that this was this service user’s wishes. This service user’s risk of developing pressure sores is high; they do have a sore on their heel and spending long periods in bed does not promote healing. There were no plans of care in place other than that of the community nurse that related to the care of the sore; no guidelines were in place to say how this service user must be cared for and how to promote healing and further development of sores. We looked at the care records for another service user who had been got up early; the plans had not been evaluated since January 2008 and they had not been weighed since 2007. This service user had seizures and although there was a care plan in place it was detailed enough to relation to their needs during a seizure episode. We continued looking at the care records for all of those service users who were up; we noted that another service user had documented on their daily notes that they had been put to bed at 6.30 pm. This service user is an insulin dependent diabetic and we noted that there were good records in place for the monitoring of blood sugar levels. During the time that we spent in the office looking at records this service user was brought in the office with us and left; we were told that they wait there for their insulin injection to be given. This service user was confused and seemed anxious that they were in a room with a stranger. The last service user’s care plan we looked at was not at all detailed and the daily notes were not very informative. This service user had been weighed on the 20 January 2008 and the action needed stated that they were to be weighed monthly, this had not been done. We observed some medicines being administered and after discussion with the manager and day and night staff confirmed to us that there was a better a safer system in place for administering and handling medication. The night staff have now received training and can administer any medicines that are prescribed at night time. The service has initiated a private audit of its St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 11 system for administering and handling medicines and have acted on its findings. We noted that those service users who are prescribed p.r.n. medication, medication (given if required) still do not have care plans in place for this activity to justify the continued use of these medicines. The six surveys received from service users were very positive about the care that thy received and told us that the staff are kind and caring. One relative we spoke with said that their relative “always looked well cared for and that the staff were always friendly and helpful and very approachable”. They did comment that their relative did like to go to bed early, as that had always been their custom; however we could find no record of this in the service user’s notes or plans of care. Another relative who was visiting during the inspection told us that they were “most satisfied and that everybody is going out of their way to be helpful and pleasant”. We chatted with some of the service users who were having their hair done and also to the hairdresser. There was a lot of laughter in the hairdresser’s room and the service users seemed very contented. They made many comments to us like “nothing is too much trouble for the staff”, “the staff are wonderful”, and “can’t grumble at all”. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The varied range of activities provided by the service means that the people who use the service have a range of opportunities to participate in motivating and stimulating activities. People who use this service have good quality food in a way that they prefer, which means that mealtimes are a pleasurable experience. EVIDENCE: Those service users and relatives we spoke with told us that the home provides many opportunities for social and physical activities. The hairdresser told us that the home “does a lot socially for the residents” and she went on to tell us that “the residents always seemed happy and enjoyed being in the home”. A relative told us that there is always something going on in the home. We viewed the programme and records for all the activities that have so far taken place. These were good records and showed that various opportunities were provided for the service users, these included ten pin bowling, skittles, snakes and ladders which is in large print to help those with visual impairment, St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 13 reminiscence sessions and visits by the local priest. The local Good Companions Club holds their meeting in the home once a year and there is entertainment and the home provides a buffet tea. The manager told us that everyone enjoys this visit and it gives those people living in the home to mix with the local community. The menus are very varied and the service users are given many choices according to their likes and dislikes. The cook tries to offer food that is traditional and adopts menus to cater for all people’s preferences. One service user we spoke with said “nobody tells me what to do and the food is quite alright”. A relative who was visiting told us that their relative liked the food; another commented that their mother liked the food. One of the ladies who was having her hair done told us that “the food is very good here and I have been here for nearly a year”. There is a very pleasant dining room and the people who live in the home choose where they eat their meals. It did not appear for those service users who had been got up early that they chose where and what time to eat their breakfast especially as some of them were unable to communicate their wishes; however we did note that those that were able chose where to have their meal. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to; however the service must ensure that all staff attend training for safeguarding adults so that the staff have the knowledge to protect service users. EVIDENCE: The comment cards that we received confirmed that the service users knew how to air their concerns and make a complaint; those service users we spoke with also confirmed this, one service user commented that “ I know who to go to make a complaint, but I do not have any, I cannot fault the home”. A relative said, “I would just chat with the manager and the staff are very approachable”. Another service user said “I don’t have any complaints, but if I did I know who to talk to”. The staff members that we spoke with told us that they were aware of issues in relation to safeguarding adults and the policies and procedures. The manager told us that they have not received ant complaints in the home and that all small issues are dealt with immediately; however there were no records in place to verify this. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 15 We noted after examining staff records that three staff members needed to attend a course for safeguarding adults, but other staff members had attended a course. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The continued refurbishment and the recognition of areas that need attending to means that the people who use the service live in a safe and comfortable environment. EVIDENCE: A full tour of the premises took place and we tested the new lift that had been installed. A number of rooms have been redecorated and some being painted in colours chosen by the service users. The bedrooms had evidence of personalisation with many effects having been brought into the home by the service users. We noted that in one room the ceiling had a large cracked and wet area, we pointed this out to the manager who immediately got the maintenance man to investigate and deal with. The laundry room has been updated and a new fridge installed for kitchen use. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 17 The overall temperature of the home has been increased, however we noted the downstairs corridor was very cold. The manager was aware of this and said that it was going to be dealt with in the warmer weather when switching off the heating would not be putting the service users at risk. The communal areas and bedrooms were found to be clean, although one bedroom smelt strongly of urine, the manager was aware of this and said that they were dealing with it. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has made some improvements in the training of staff, which means that better outcomes should be achieved for people using the service. EVIDENCE: We looked at the duty roster for the past week and the current week. The current week tallied with those staff who were on duty and this roster and the past weeks roster confirmed that the home is adequately staffed to ensure that the service users’ needs can be met. We looked at the records for two newly appointed staff members and these contained all the necessary recruitment documents including two references and Criminal Record Bureau Checks. We checked the training records for staff and these indicated that some training had taken place, although one member of staff we spoke with said, “ I have not done any training for quite a while”. One senior carer was doing NVQ level 4, another one was going to do some IT training, another member of staff were due to start NVQ level 3. A number of staff are in need of an up date in fire training and, as already mentioned, there are a number of staff who need some training in safeguarding adults. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 19 We saw a record for induction training for one new member of staff. The staff are enthusiastic about the work they do and are very caring and were observed to treat the service users with respect and dignity. Two staff members we spoke with were clear about their roles. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are meeting the needs of the service users. EVIDENCE: Those relatives and service users we were able to speak to felt that the home was managed well and the staff also felt that they were supported in their role. The proprietor usually visits once a week and speaks with the manager on a daily basis and the manager told us that she feels well supported. We looked at some policies and procedures that were related to those standards we inspected and noted that some of them had not been updated St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 21 for some considerable time, however the manger informed us that she was in the process of updating them. Staff told us that they received supervision and we noted that these sessions are recorded. The manager has been proactive in addressing quality issues within the home; satisfaction surveys had been given to relatives and service users to find out how they could make improvements and we were able to sample these; this information now needs to be documented so that the service can show what improvements have been made in relation to these surveys. Those records that we looked at demonstrated that health and safety issues are regularly reviewed and equipment serviced at the appropriate times. A fire risk assessment has been carried out by a professional agency and in response to their report a new fire door is being installed in the laundry room. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 22 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 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 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 2 X X 3 2 3 St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 (2) (a) (b) (c) Requirement All people using the service must have an up to date, detailed care plan. This will ensure that they receive person centred support that meets their needs. All staff must be adequately trained in the work they are to perform, this will ensure good outcomes for the people who use the service. People who use the service must have medicines prescribed on p.r.n. (as prescribed basis) given to them by staff only when clinically justified and this can be demonstrated by record keeping practices. Timescale for action 20/06/08 2. OP30 18 (1) (i) 20/08/08 3. OP9 13 (2) 20/07/08 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 Good Practice Recommendations DS0000061993.V367139.R01.S.doc Version 5.2 Page 24 St Mary`s Residential Care Home 1. 2. Standard OP12 OP33 The activities records should be linked to the care planning system to ensure that all service user’s needs in this area are being met. The present system for reviewing and improving care should be made more robust particularly in recording information that has been gathered to ensure that people who use the service receive a more holistic service. St Mary`s Residential Care Home DS0000061993.V367139.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V367139.R01.S.doc Version 5.2 Page 26 - 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. 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