Inspection on 06/10/05 for St Mary`s Residential Care Home

This inspection was carried out on 6th October 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 03/05/05

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

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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 Mary`s Residential Care Home Market Place New Buckenham Norwich Norfolk NR16 2AN Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 6th October 2005 09:40 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.V255804.R01.S.doc Version 5.0 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.V255804.R01.S.doc Version 5.0 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.V255804.R01.S.doc Version 5.0 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 3rd May 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.V255804.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of seven hours, two visits had to be made as documents were not available for inspection on the first visit. Opportunity was taken to inspect care records and policies and communicate with staff members and several service users. The manager was not present for the first inspection and a senior carer very ably accompanied the inspector. What the service does well: What has improved since the last inspection? Many improvements have been made to the external environment, all guttering has been made safe, waste matter is now stored in a safe area whilst awaiting collection. The internal electrical system has had a full inspection. Service users are now admitted to the home after a full needs assessment has been carried out. Two references are now obtained for all new recruits. The attached cottage has been renovated and is used for supervision sessions, training purposes and for relatives if they wish to stay or for privacy. New carpet has been laid in the front hall, sitting room and dining room. bedrooms have been decorated. Two St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 6 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.V255804.R01.S.doc Version 5.0 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.V255804.R01.S.doc Version 5.0 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): 3,5, Assessment of prospective service users has improved. EVIDENCE: New service users are now admitted to the home after a full needs assessment has been carried out; this was confirmed by examining records of a service user that had recently been admitted to the home. The Inspector chatted to one service user who was visiting the home for the day; she informed the inspector that she was spending odd days at the home so that she could ultimately decide if the home was suitable to meet her needs. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 9 St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, There has been little improvement in the management of care planning and meeting the assessed needs of the service users. EVIDENCE: Although it was recommended in the last report that carers be given some training in care planning, this has not taken place. Inspection of the care plans revealed many areas that give rise for concern and without appropriate records of prescribed or given care leads to confusion and uncertainly whether assessed needs are being met. One service user was identified as being epileptic but there was no plan of care for this or how to deal with seizures. Another service user had been identified as being prone to developing pressure sores on heels; a skin integrity assessment had not been carried out. One service user was prone to falling, however there was no risk assessment in place to address the risks involved for this resident in relation to falls. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 11 The Inspector noted that many of the care plans had not been evaluated since June 2005 so she was unable to assess if needs are being met, a requirement is made to ensure that the plans of care are evaluated and reviewed on a monthly basis and more if necessary in accordance with the changing needs of each service user living in the home. It is recommended that the manager ensures that all staff receive appropriate training in care planning to encourage best and safe practice. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Activities within the home are not well managed. EVIDENCE: Very few activities take place within the home setting, it would appear that the only activity on offer once a week is bingo; a number of the service users expressed disappointment in not being able to engage in other activities. Some of the service users have been out on the Broads in the summer months, but not all could utilise this outing. Entertainment is brought into the home once a month in the guise of a ‘sing along’, however this does not meet every ones expectations. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 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 Arrangements for dealing with complaints are satisfactory. Service users could be better protected. EVIDENCE: Service users spoken with indicated that they would speak with the manager or their carers if they had a complaint or a concern. The procedure for making a complaint is readily available and given to all service users and their families on entry to the home. This was clearly written but a recommendation is made to bring it up to date with current information. No records were available in relation to any complaints and a recommendation is made to rectify this. It is also required that the home ensures all records are available for inspection purposes. The Inspector was unable to inspect documents relating to POVA checks and Criminal Record Disclosures; this necessitated a second visit to the home to ensure that these disclosures were in place. On the second visit the Inspector ascertained that many of the staff did not have Criminal Record Disclosures and an immediate requirement was issued to ensure that service users are protected at all times and that they live in a safe environment. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 14 For a second time a requirement is made to ensure all staff attend adult abuse training sessions as this has yet not happened. It is also recommended that all policies and procedures in relation to Abuse and Vulnerable Adults be updated and revised to make sure that they are in line with current legislation. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Parts of the internal environment need to be in a better state of repair. The home was clean and tidy. EVIDENCE: A tour of the home took place and many of the rooms were inspected. Part of the carpet upstairs was in a state of disrepair and needs to be replaced, it could, if allowed to further disintegrate, become a safety hazard. It is recommended that further consideration be given to refurbishment. The Inspector did note that a new carpet had been provided in the front hall, sitting and dining room. The home appeared clean and hygienic throughout. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30 Service users needs are not entirely met by the numbers and skill mix of the staff. Service Users are not well supported and staff are not totally trained in all areas to meet the service users assessed needs. EVIDENCE: During the first visit the Inspector was unable to access records for training and a second visit had to be undertaken. A requirement is issued to ensure that records are always made available for inspection purposes. Some training has been undertaken but records show that it is very scant and needs to be promoted to make sure that all staff have the skills and knowledge to safely meet the needs of the service users in their care. Those staff members that the Inspector spoke with also confirmed this. Two new overseas carers had been employed but there were no induction records for the Inspector to access to confirm that an induction had taken place. A requirement is made to ensure that all new recruits are appropriately inducted and records kept. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 17 There are some very competent senior carers in place who would benefit from further training in care planning and thus enhance their skills and ensure that they become knowledgeable practitioners. It is also recommended that the manager updates her skills in care planning, this would enable her to fully support the staff in the whole care planning process. At the time of the first inspection visit there were four carers on duty one of whom was being shadowed by a new member of staff. Two of these were also senior carers one of which was acting up in the absence of the manager. There appeared not to be sufficient skilled carers on duty to meet the assessed needs of the residents, as one of the senior carers was taking care of administration duties. The Inspector ascertained from the two overseas carers that they were not sufficiently knowledgeable about care of the elderly and needed quite a lot of extra supervision; no real guidance had been given to these carers on their entry to the home and it would appear that their supervision was very much left to the senior carers who were trying to meet the assessed needs of the residents as well as supervise new staff. The home needs to do a lot of work to maintain NVQ training as records showed very poor figures for attainment. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 18 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): 31,32,33,36,37,38. There is no clear leadership within the home and direction to staff; this results in some practices that do not promote or safeguard the welfare and safety of the residents. EVIDENCE: The manager does not make clear management arrangements for the home especially in her absence. Records are not available for the inspection process. The Inspector gained the impression that staff are unclear of their roles within the structure of the home, it was also established that the manager does not yet have a job description. There is no designated deputy to undertake full responsibility in the absence of the manager and the senior carers are not given a proper handover for this activity. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 19 Whilst many of the service users made positive comments about the staff and their kindness towards them, the Inspector felt that the home would benefit from a more structured approach. It is recommended that consideration be given to the deployment of a designated deputy manager. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 20 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 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 2 2 2 2 St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? yes 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 ensure that unnecessary risks are to the health or safety of service users are identified and so far as possible eliminated. The registered person shall consult service users about a programme of activities arranged by or on behalf of the care home and provide facilities for recreation including having regard to the needs of service users, activities in relation to fitness and training. The registered person shall make arrangements by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall not employ a person to work at the care home unless subject to DS0000061993.V255804.R01.S.doc Timescale for action 23/10/05 2. OP8 13 23/10/05 3. OP12 16 (2) (n) 23/10/05 4. OP18 13 (6) 23/10/05 5. OP29 19 (1) (b) 11/10/05 St Mary`s Residential Care Home Version 5.0 Page 22 6. OP18 17 paragraph (6) he has obtained in respect of that person information and documents specified in (1) paragraphs 1-7 of Schedule 2 The registered person shall ensure that records are available for inspection in the care home by any person authorised by the CSCI 23/10/05 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. 5. Refer to Standard OP16 OP31 OP38 OP19 OP31 Good Practice Recommendations It is recommended that the procedure and policy for complaints is updated and a record of issues and concerns brought to management be kept. It is recommended that the manager has a job description to enable her to perform her role. It is recommended that the policies and procedures be updated to fit in with current practice and legislation. It is recommended that consideration be given to further improving the décor and furnishing of the home. It is recommended that consideration be given to the appointment of a deputy manager. St Mary`s Residential Care Home DS0000061993.V255804.R01.S.doc Version 5.0 Page 23 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. 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