Inspection on 03/05/05 for St Mary`s Residential Care Home

This inspection was carried out on 3rd May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Mary`s Residential Care Home 20/05/08

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St. Marys Residential Care Home Market Place New Buckenham Norwich NR16 2 AN Lead Inspector Marilyn Fellingham Announced 3 May 2005 9.30am 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 I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service St. Marys Residential Care Home Address Market Place New Buckenham Norwich NR16 2AN 01953 860956 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) Jasvinder Paul Singh Banga Mrs Daphne Fulcher Care Home 29 Category(ies) of Old Age (28) Dementia - over 65 (1) registration, with number of places St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 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 19 November 2004 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. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and it took place over seven hours. A tour of the premises took place and staff and care records were inspected. One provider, the manager, four care staff one domestic, one GP and one relative were spoken to; eight residents were spoken to at great length. What the service does well: What has improved since the last inspection? An effort has been made to ensure that all new residents are assessed appropriately, thus making certain that all their needs can be met. A new communal room has been made available which residents can use for quiet moments or receiving visitors in private. A new medicine trolley has been obtained, a new food mixer for kitchen use and two rooms have been re decorated and new carpets laid. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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 I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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) 1,2,3,4 There is adequate information available to assist prospective residents to make an informed choice about admission to the home. Prospective residents and their relatives are given the opportunity to visit the home prior to admission. There has been improvement in the assessment procedure for assessing prospective residents before admission. EVIDENCE: The statement of purpose contains very useful pertinent information. Assessment documentation was available for those new admissions to the home; these assessments provided sufficient information in order for a suitable decision to be made as to whether their needs could be met. This information was also detailed enough to plan care. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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) 7,8,9,10,11 Although progress has been made in the assessment process for all new residents admitted to the home, this information has not been used to formulate comprehensive plans of care. The care plans that are in place do not identify aspects of care required to ensure that all needs are being met. The carers need to receive training in various aspects of care planning in order for them to understand the significance of recording the care that they give. Residents are treated with respect and dignity. Care of the dying is handled well. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 10 EVIDENCE: Individual care plans were in place but these failed to detail all needs and the relevant care required to ensure that all needs are being met. The care plans also failed to identify if care is evaluated or reviewed. Some residents having been identified as needing help with their daily hygiene had no associated plans of care in place. Although assessments have been made to identify those at risk of developing pressure sores, these results were not reflected in a care plan for the prevention of pressure sores. Other areas of need had been identified, one resident had been identified as having mobility problems due to a stroke, no care plan was in place to indicate to care staff how to mobilise him in relation to his right- sided weakness or how to deal with his hygiene needs. Three more residents were acknowledged as being diabetics but once again there were no care plans in place to meet their overall needs in relation to their diabetic condition. This approach is very much dependent on staff memory and good communication systems. Residents are at risk of not having their health needs met if these informal systems break down. In general care plans were not in place to correspond to information recorded on assessment documentation and progress notes. Discussion with staff members highlighted that they knew what care should be given, but that they had not had sufficient information and training with regard to care planning. The assessment documentation, in many cases referred to residents at risk of falling, however in most of these cases no risk assessments were in place with particular attention to falls. A random check of MAR charts revealed that there had been improvement in signing for all medication given or refusal of. Discussion with management and examination of letters received from grateful relatives gave the overall impression that care of the dying was handled very well. Accommodation is offered plus meals whilst relatives are visiting the dying. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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 standard(s) 12,13,14,15 Social activities are improving and much more scope is being offered or considered in order to meet the needs and expectations of the residents. However, scant records are in place for those activities that have taken place, with no reference to the level of participation by the resident. Residents are given opportunities to make choices and take control over their lives; contacts are maintained with the community. Meals are managed well and are nutritious and well received. EVIDENCE: A number of residents were spoken to, all of whom said that there was always something of interest going on in the home. A monthly timetable of activities is on display so that residents are aware of and able to choose what activities they wish to engage in. A number of visitors also enjoy taking part in the activities and they use the timetable of events also. The timetable also indicates to relatives and residents when the next residents meetings are. These are useful with pertinent observations being made particularly ideas raised about activities and what the residents like doing. The manager said that most of the ideas raised about activities are going to be introduced; such as flower arranging and art classes. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 12 Three of the residents have attended a local Good Companions Club with the view of becoming members. There is very little evidence of recording activities that have taken place. Residents relatives are encouraged to visit and can enjoy meals with them. The meals are well thought out and the food is both wholesome and appealing and all of the residents spoken to said how wonderful the food was and it was evident that choices about meals were constantly being made. The inspector noted that the cook even chatted to a resident in the dining room to ascertain what she could give her to tempt her to eat something. To ensure good communications are maintained within the working environment of the kitchen the two cooks always work one day together to make certain that the kitchen runs smoothly and that they can meet the needs of the residents. It was noted by the Inspector that those residents requiring help with feeding were assisted in a most empathetic way. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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 standard(s) 16,18 A complaints procedure and policy is in place, however it needs to be revised. There have been no complaints made to the home or the CSCI, small observations are made but not recorded. There has been no effort by the home to ensure that all carers are in receipt of abuse training to ensure residents are protected from all forms of abuse. EVIDENCE: The home has a clear complaints procedure but it needs to be revised to ensure that all residents, relatives and friends are clear about the timescale for dealing with all complaints. Although small issues are often dealt with on a daily basis these are not recorded and therefore the home cannot demonstrate that it has addressed them. Although some carers who are in receipt of NVQ level 2 and covered some aspects of abuse the training records indicated that all staff need instruction in this subject. The residents spoken to all expressed that they felt that they were treated well and with dignity and respect; in no way did they feel they were abused or taken advantage of. They were aware who they could talk to if they had any concerns. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 14 St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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 standard(s) 19,20,21,26 Some improvements to the décor and facilities have been made. There are areas that need to be addressed to ensure that residents are living in a safe environment. There are not sufficient assisted bathing facilities. EVIDENCE: There has been new ownership of the home during the past year and a number of changes to the environment have taken place and plans are in hand to make other changes. The home was found to be very clean and tidy and it gave the impression of being very homely. • • • Two rooms have been re decorated and new carpets fitted. Carpets need making safe on entrance to two rooms. Some paintwork in the main downstairs corridor needs addressing. I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 16 St. Marys Residential Care Home • • A new room has been made available for residents; this has extended the amount of communal space for use by the residents. Until the new plans are activated the number of assisted baths is considered not suitable to meet the needs of the residents. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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 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) 27,28,29,30 The procedure for obtaining references needs to be more robust to enable the protection of people living in the home: all other relevant checks are made. The home as far as is possible always has an adequate number of carers, domestic staff and kitchen staff to meet the needs of the residents. EVIDENCE: The staff files indicated that in some cases only one reference was obtained. Criminal Records Bureau checks have been made and these were seen, one was outstanding for a new member of staff, which was being followed up. The staff rotas indicated that the home is always adequately staffed over a twenty-four hour period. Domestic staff are employed to ensure that carers are not taken away from their caring duties. The home has taken steps to ensure that at least 53 of its caring staff have NVQ level 2 or 3. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 18 Inspection of records, training records and discussion with staff revealed that more training was needed in relation to the activity of care planning. This will make certain that staff are competent in care planning and that the residents needs are being met and that they are in safe hands. Residents spoken to stated that the staff were all very, very kind and caring. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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 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) 31,33,34,35,36,37,38 There is improvement in leadership skills in some areas, however there is a lack of leadership and guidance in other areas to ensure the care planning system is appropriate to meeting the needs of the residents. Formal supervision of staff has improved. The home is run in the best interest of the residents and they are safeguarded by the accounting and financial procedures of the home. On the whole the health, safety and welfare of the residents and staff are promoted and protected. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 20 EVIDENCE: It was clear after discussion with management and staff that there has been a lack of guidance in relation to care planning. The manager has completed NVQ level 4 and is pursuing other studies such as attending a study day on risk assessments, by doing this she hopes to achieve a better understanding of her responsibilities as a manager: it is also hoped that this will be aided by the production of a manager’s job description. The new provider was able to produce documents from his accountant to provide evidence of financial viability. The home has produced a quality assurance survey and has responded to comments made by relatives and residents; however these responses need to be recorded so that the home can demonstrate that they have responded to the survey and thus provide evidence that they are monitoring the quality of care. Residents meetings are held on a regular basis and minutes of these meetings were seen, the home once again has responded to comments made but has failed to document these responses. As already mentioned the care has not been evaluated, when this happens it is another way of monitoring the care that is being given. Records showed that the home has had regular fire instruction; the staff confirmed this. Staff training records confirmed that new staff receive appropriate induction and training. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x 2 3 x 3 3 3 St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 22 Yes 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 7 Regulation 15 Requirement The registered person shall ensure that a written plan as to how the service users needs`in respect of his health and welfare are to be met and keep them under review. The registerd person shall ensure that the home is kept in a good state of repair internally and repairs are made to carpets.. The registered person shall ensure two references are obtained Timescale for action Immediate requiremen t made 2 weeks Immediate and on going Immediate and on going 2. 19 23 3. 29 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 3 12 31 33 Good Practice Recommendations It is recommended that assessments are carried out for those residents that have been in the care home for a number of years, this will enable their needs to be met. It is recommended that activity care plans are formulated. It is recommended that the manager has a job description to enable her to perform her role. It is recommended that records are kept to demonstrate how results of surveys are activated or addressed. I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 23 St. Marys Residential Care Home 5. 6. 16 18 It is recommended that a record is kept of minor issues brought to the attention of the home by relatives, residents or friends. It is recommended that all staff attend sessions on adult abuse to increase their knowledge and understanding of the subjest. St. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection 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. Marys Residential Care Home I55 S61993 St Marys V216379 030505 Stage 4.doc Version 1.20 Page 25 - 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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