CARE HOMES FOR OLDER PEOPLE
St Marys Residential Care Home 14 Westbrooke Worthing West Sussex BN11 1RF Lead Inspector
Philip Barker Unannounced Tuesday, 24 May 2005 V224229
th 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 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 Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service St Marys Residential Care Home Address 14 Westbrooke, Worthing, West Sussex, BN11 1RF Telephone number Fax number Email 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 Mrs Anne Fitzerald Care home only (PC) 25 places Category(ies) of Old age, not falling within any other category registration, with number (OP) 25 places of places St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th October 2004 Brief Description of the Service: St Mary’s Care Home is a home for older people registered to accommodate twenty five residents. 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 and the registered manager is Mrs Anne Fitzgerald. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place from 9-15am to 12-45pm. St Mary’s has performed well over the past years and at the last inspection no requirements were made. During the course of this inspection the inspector spoke to residents and staff. Some residents spoke to the inspector in their own rooms, others spoke to him when he joined them in the lounge for morning coffee. The manager was not present at the time of the inspection so a Senior Carer assisted the inspector. Records and Care Plans were looked at and a tour of the home was conducted. All the residents that were spoken to were very positive about the care they were getting at the home. One lady who had been in the home for some years said, “ I am so lucky to be here”. Another said, “So happy here, lots of nice people.” One gentleman even said that, “everything is perfect”. This was the general opinion from those residents who chose to speak to the inspector. Staff training was ongoing and it was noted that the majority of staff were either National Vocational Qualification (NVQ) trained or were on training. The training records of all staff were well documented and up to date. The manager was supervising staff and detailed notes had been kept of these sessions. The building was warm, clean and welcoming. There were four care staff on duty plus the Senior, six domestics, a cook and a maintenance man. At night there were two staff awake on duty with backup to a senior member of staff. The rotas showed this to be the case. The Home had recently been assessed for ‘The Investors In People Award’ which to their credit they had passed. The home had recently had an inspection from the Fire Officer and the Environmental Health Officer. No adverse comments were left. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 6 What the service does well: 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 Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 standard(s) 3, 6 Residents and their families have the information they need to make an informed choice about where they live and are suitably assessed before placing. EVIDENCE: Each resident is given a contract when he/she enters the home. Most of the residents had family or friends who were able to act upon their behalf. One resident said, “I leave all that to my son”. The manager assesses all residents before they join the home either in their own home or in hospital. These completed assessments are kept in the Care Plan. The home does not take anyone in for intermediate care. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 The resident’s health, personal and social care needs are well met through training and supervision of the staff. EVIDENCE: Care Plans were well written and contained all the information necessary to look after the residents. They were updated regularly and reviewed at least once a month. The inspector looked at the Care Plans of some of the residents he had spoken with and felt that the care given was accurately recorded. District nurses visit the home when requested and records are kept of all such visits. Medication was stored safely and records were well kept in regard to the administering and disposing of them. Five residents were able to look after their own medication and locked drawers were provided to keep them in. Staff were well trained and some had recently attended an outside course on ‘Safe Handling of Medicines’. When looking around the home the inspector noticed staff knocking before entering rooms. Residents were called by their chosen name; others preferred to be addressed as Mrs. The inspector spoke to residents in their rooms and in the lounge and privacy was observed.
St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13, 14, 15 Residents say that they are happy with their lifestyle, are able to keep in contact with their family and friends and able to have control over their daily tasks. Good home cooked food is provided. EVIDENCE: One resident told the inspector that she was happy to stay in her own room and did not get too involved in activities “I prefer to stay in my room with my radio although I do go to special events”. The home does provide some activity for the residents if they wish to join in. There are regular afternoon activities that are advertised on a wall in the lounge. There is a Mass held every morning to which the majority of residents attend. The inspector watched as staff helped residents into the Chapel for the service. The majority of residents are able to go out with their families or friends and one lady told the inspector that she goes out shopping in the town. A resident has taken upon himself the task of videoing TV programmes that others might not see and these are shown in the evening to a number of delighted residents. It was a blustery day so no-one was outside in the garden although there was evidence from benches that some had been outside when it was warmer. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 11 Family visits are important and the inspector was told that all visitors were offered refreshments. Sadly no visitors were present during the inspection so the inspector was unable to talk to any relatives. The residents sat down to a meal of Roast Lamb or Chicken, Runner Beans, Carrots and Roast Potatoes followed by Rice Pudding or Stewed Apple. There was also a choice of salad and biscuits and cheese. Two special diets were catered for and the inspector was told of alternatives that the two residents might have. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 standard(s) 16, 18 Any complaint is taken seriously and staff and residents know how to complain. Staff are well aware of the Adult Protection Procedures and a Whistle Blowing Policy is in evidence. EVIDENCE: All staff have attended the Adult Protection Training and the procedures are in the office. There have been no complaints made about the home to the CSCI. The Complaints Book has minor complaints made about the home written in it. One such complaint concerns a blouse that was damaged whilst being ironed. The home replaced the item at their own cost after consulting with the resident. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 standard(s) 19, 26 The home is well maintained, safe and clean with no nasty smells. EVIDENCE: The home is well kept and is clean and tidy. The inspector observed the cleaners doing their rounds and every room was left clean and tidy. The home has undergone considerable refurbishment over the past five years. This is still on going and rooms are redecorated when they become available. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 There is usually sufficient staff employed to ensure that residents’ basic needs are met. The home has a sound recruitment policy and all checks are made. There has been considerable input into staff training. EVIDENCE: All staff have undergone Criminal Records Bureau (CRB) checks and copies of these were kept in the office. Prospective staff are invited to complete an application form and attend an interview. Staff training had been undertaken in all areas and the evidence showed that all staff are offered training relevant to their work. Nine staff have a National Vocational Qualification (NVQ) at Level 2 or above and a further four are studying for the Level 2 at this time. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 38 It is apparent that the needs of the residents are paramount and that things happen for their benefit. The home has no dealings with any personal finances preferring to leave that to families or other professionals. EVIDENCE: The home was constantly updating their practices to ensure that residents received the best care that they could. The home does not have any dealings with any money belonging to residents. Fire and Environmental Health Requirements had all been met and all equipment is regularly serviced. St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 17 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations St Marys Residential Care Home H60 H11 S14738 St Marys V224229 240505 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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
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