Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 14/04/05 for St Mary`s Residential Home

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

This inspection was carried out on 14th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The people who live at St. Mary`s appeared bright and happy when moving around the building and the conversations held at lunchtime were lively and involved many of the people in the dining room. The staff were cheerful and on asking, appear to love their work. One staff member was singing most of the time he was working and it was noted how this was enjoyed by the people he was assisting at the time. No one appeared rushed and there was a calm atmosphere as the tour of the building took place. Activities when the organiser or volunteer is in the building are enjoyed.

What has improved since the last inspection?

In the two and a half months since the last inspection very little has improved. Most of the requirements are still outstanding. One area which is about to improve is the dining area flooring that is to be replaced with a wooden anti slip surface to replace the carpet.The Home now has a Deputy Manager in post and aims for developing this role are being planned to aid the improvement of the service. A staff member has recently qualified as a trainer for moving and handling that will assist the staff in the up to date methods of working safely as part of their induction and yearly updates.

CARE HOMES FOR OLDER PEOPLE St Marys North Walsham Road Crostwick Norwich NR12 7BQ Lead Inspector Ruth Hannent Unannounced 14th April 2005 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 I55s27467stmarysv221275140405(4).doc Version 1.20 Page 3 SERVICE INFORMATION Name of service St Marys Address North Walsham Road Crostwick Norwich NR12 7BQ 01603 898277 01603 891105 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) County Healthcare Ltd, a wholly owned subsidiary of Fours Seasons Health Care Ltd Linda Bowker-Howe Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Forty-Four (44) Older People of either sex, not falling into any other category, may be accomodated. Date of last inspection 26th January 2005 Brief Description of the Service: St. Mary’s is a large single storey building situated in the village of Crostwick.The accommodation consists of thirty-two single and six double bedrooms. Thirty-three bedrooms have an en suite facility. There are a variety of communal areas for the use of service users.St. Mary’s is situated in its own grounds with a large car park to the front of the premises St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours with the Manager. A poster was placed on the notice board to inform visitors and people who live at St Mary’s that the Inspector was available to talk to them and comment cards were left with the Manager to be filled in by the residents or visitors. A discussion regarding the previous inspection requirements and recommendations along with a complaint that had been received by the Inspector took place. A tour of the building with some time to talk and observe the people who live at St Mary’s and the staff was the main focus of this inspection. Some pre admission assessment reports, care plan records and the and latest two staff recruitment files were looked at. A meal was taken with the 34 residents and conversations were held with 8 of those people throughout the day. 5 care staff were spoken to along with a senior carer and the handyman. What the service does well: What has improved since the last inspection? In the two and a half months since the last inspection very little has improved. Most of the requirements are still outstanding. One area which is about to improve is the dining area flooring that is to be replaced with a wooden anti slip surface to replace the carpet. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 6 The Home now has a Deputy Manager in post and aims for developing this role are being planned to aid the improvement of the service. A staff member has recently qualified as a trainer for moving and handling that will assist the staff in the up to date methods of working safely as part of their induction and yearly updates. 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 I55s27467stmarysv221275140405(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 I55s27467stmarysv221275140405(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) 3 and 5 Progress needs to be made to the admissions process to ensure the correct care and expectations of the person requiring the placement and their families can be met. EVIDENCE: Although the Home has a blank format for carrying out assessments prior to people being admitted the Manager was unable to show a completed form for the last two people admitted. One person had arrived to visit and had stayed but no assessment/pre visit by a senior staff member had occurred. (Requirement) The Statement of Purpose and Terms and Conditions have not been updated as required on the last inspection. (Repeated requirement). Family members and friends are invited to visit to check the suitability of the home prior to admission. Besides a brochure they are given a form to complete, asking for information on the social needs, to aid the staff in understanding those needs for the older person. 2 forms seen gave very little information and one appeared a little negative with the comments read. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 9 St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 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 standard(s) 7,8,and9, Clearer recording practise and collating of information needs to be in place to ensure that evidence is available and that the correct practice is happening. Monitoring of this service is very difficult if records are not clear and staff do not have clear guidelines to follow. EVIDENCE: The care plans for residents are spread over various pieces of paper and information to track the individual needs of each person was hard to achieve. (Requirement) It was evident that the health care needs were being met to some residents as seen was the medication procedure at lunchtime which was carried out correctly. The health needs of a service user who was in bed had the correct charts in the room to monitor fluids and turning. (Some gaps in signatures on the turning chart were noted) and a physiotherapist was visiting on the day of inspection to give therapy to a person who had a broken wrist giving dates for ongoing sessions. In the discussion with the Manager and on walking the building it was noted that each room had a lockable drawer. This is for medication if the person St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 11 wishes and is, after a risk assessment, able to manage their own medication. At the time of inspection no one was responsible for their own medication except one person who takes their own insulin that is locked in the medical room fridge. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 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 standard(s) 12,13 and 15 The people who live at St. Mary’s are happy with the way they live and it meets their expectations. Meals and activities need to involve the residents more, allowing choice. EVIDENCE: 8 of the people who live at St. Mary’s were spoken to at different times of the day and quite a long time was spent discussing their days and the care they receive. Although they were full of praise for what the home offered and the care the staff give some wanted more but did not think to ask for it. One lady would love to be more active within the mornings saying “not much goes on in the mornings but the staff are busy”. “The television is on but it is just a noise”. Many of the people talked about their families and how often they visit or take them out for lunch or a car ride. This is encouraged by the home and notices and posters were seen asking families to be involved within the home and future events that were planned. The lunchtime meal was shared with all the people in the dining room (3 people had their meals in their room). Although the meal was wholesome (chicken pie, mash, carrots, peas and beans) there was no menu on display and on asking prior to the meal none of the residents knew what was for lunch. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 13 It was not evident that people were offered a choice although there was an alternative, if it had have been made clear. (Requirement) St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Systems for the protection of the people who live at St. Mary’s is in place at the recruitment stage but training to update the staff’s knowledge is needed on protection of vulnerable adults. EVIDENCE: 2 staff records seen showed the correct procedures for checking records for both CRB and POVA had taken place. Confusion occurred when the manager did not gain another CRB for a new employee who had a check completed in the last 12 months in a previous post. This was to be rectified immediately by the Manager. Training to date has not taken place within the staff team on the protection of vulnerable adults and should be implemented as soon as possible. (Requirement) The home has a whistle blowing policy and 2 staff on questioning understood what the policy was about. St Marys I55s27467stmarysv221275140405(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) 19,21,24,25 and 26 Residents at St Mary’s live in a safe and well-maintained environment. Some bedroom areas presented an unpleasant odour that is not acceptable. EVIDENCE: The Home is a modern building which is well decorated with suitably furnished rooms in all areas. The handyman was on duty and assisted the fire alarm service company who had arrived to do their 6 monthly checks.(1 smoke detector was found to be faulty and replaced immediately). Fire extinguishers were looked at and it was noted they were serviced in June 04. 3 bathrooms and 2 flat floor shower rooms were seen and the majority of bedrooms have an en suite facility. Accessibility to these facilities for the people at St. Mary’s was within easy reach wherever in the home a person may be. The private space for each person was furnished appropriately with personalised touches within the rooms. Each bedside cabinet had a lockable drawer for valuables or medication and some people had their own telephones. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 16 Although the home was clean and tidy with a well organised laundry that appeared to be managing the incontinence within the home there was still areas in some bedrooms that harboured unpleasant smells and appeared to come from the carpets. This was discussed and although the carpets are shampooed regularly the problem appears deeper than the carpet pile. (Requirement) St Marys I55s27467stmarysv221275140405(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,and 29 The deployment and numbers of appropriately experienced/trained staff was sufficient to meet the needs of the residents on the day of the inspection but would need reviewing if the numbers of residents increase to full capacity. EVIDENCE: On the day of inspection 5 care staff, 1 cleaner, 1 laundry lady and the handyman were seen and spoken to. (2 staff were in the kitchen but not spoken to) The staff were observed going about their duties in a caring professional manner with appropriate conversations heard between the staff and residents. The rota for the week showed 5 staff covering the morning shift and 4 staff for the evening shift with 2 waking staff over night which was seen as adequate for the care of 34 residents. (This number will need to be looked at if the home increases to its full capacity). The recruitment of the 2 latest members of staff were seen and a clear process of application, interview, references CRB and Pova checks were in place. Each person had an induction pack with one nearly completed and signed and one yet to be started. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 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 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) 35, 36 and 38 Residents at St. Mary’s have their personal money safeguarded by good recording of money transactions that take place on their behalf. Staff are not appropriately supervised. Some areas of protection of the health and safety of residents was in place but other areas need to improve. EVIDENCE: People at St. Mary’s keep a certain amount of money in the safe for items such as cigarettes or hairdressing charges. It was noted that each person had a written account held in the office of the money paid in and out with two signatures for each transaction. The family members bringing in this money receive a duplicated top sheet for their own records. (There is only a small amount for each person kept in the safe). Some residents hold their own money if they so wish. The supervision of staff showed minimal records that gave very little detail and value to what these one to one sessions should entail. The Manager is about to St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 19 start a round of staff supervision sessions but to aid the full staff team in the understanding, a training session on what these sessions should entail would be advisable. (Requirement). On walking the building some areas but one were seen as managed in a safe way. The fire exits were clear. Infection control was being practiced within the care service offered by the wearing of disposable gloves and aprons. The staff covered their uniforms when serving meals and the laundry was done at the correct temperature and separated as required for soiled items Fire equipment was appropriately placed and the service of this equipment was within date. The one concern was on running the hot tap in the bathroom with the special Arjo bath the temperature went up to 53 degrees and was too hot for the hand. This bath has its own thermostatic control that was either broken or set too high. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 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. 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 x x 1 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 x COMPLAINTS AND PROTECTION 3 x 3 x x 3 3 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x 3 2 x 2 St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 21 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 5 Regulation OP2 Requirement The Manager/Proprietor must produce a statement of Terms and Conditions to ensure the Statement of purpose can be completed and all service users receive a copy. This is a repeated requirement from the last 2 inspections. The Manager must ensure that all potential people moving to St.Marys are assessed as suitable and the findings clearly recorded The manager must have clear documentation of care needs on a care plan that is person centred The Manager must ensure that every opportunity is given to offer choice of meals using different methods and tools to show the menu to all residents. The Manager must deliver a training programme to all staff on the Protection Of Vulnerable Adults The Manager must replace the carpets in the areas that contain the unpleasant odours with a more suitable floor covering. The Manager must ensure I55s27467stmarysv221275140405(4).doc Timescale for action May 31st 2005 2. 3 OP14 May 31st 2005 3. 7 OP15 June 30th 2005 May 31st 2005 4. 15 OP16 5. 18 OP18 June 30th 2005 June 30th 2005 June 30th Page 22 6. 26 OP16 7. St Marys 36 OP18 Version 1.20 appropriate supervision sessions are planned and recorded for staff one to one meetings at least 6 times a year.. 2005. 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 15 Good Practice Recommendations It is recommended that staff do not wear plastic aprons when serving meals but attractive butcher type aprons with pictures on that will encourage conversation and interaction in the dining room. St Marys I55s27467stmarysv221275140405(4).doc Version 1.20 Page 23 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 I55s27467stmarysv221275140405(4).doc Version 1.20 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!