Inspection on 10/10/07 for St Marys Care Centre

This inspection was carried out on 10th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Marys Care Centre Beverley Road Anlaby East Yorkshire HU10 7BQ Lead Inspector Eileen Engelmann Key Unannounced Inspection 10th October 2007 09:00 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 Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Care Centre Address Beverley Road Anlaby East Yorkshire HU10 7BQ 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) 01482 659525 01482 307593 Private Medicare Limited vacant post Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (60) of places St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Physical disability - Code PD The maximum number of service users who can be accommodated is: 60 New Service 2. Date of last inspection Brief Description of the Service: St. Mary’s Care Centre is a new purpose-built care home, which provides a service for people who meet the following criteria of need – Older people and those with a physical disability. The home is situated off Beverley Road in Anlaby, a highly regarded residential area, adjacent to a private hospital and private sheltered accommodation. The care home has been designed and built to the specifications of the Directors of Private Medicare Limited and their architects Gelder and Kitchen. Accommodation is provided in sixty spacious, en-suite rooms with four different room designs. Each bedroom is provided with an electric profiling bed, nurse call system, fridge, shower room/en-suite, ridged grab rails and other adaptations to meet the needs of older people and those with disabilities. All rooms are single, however an interconnecting lockable door between two single rooms is also available should a couple require this facility. People living in the home are provided with a wide variety of communal spaces including lounges, a television room, cinema room, library and music room, a large spacious dining room, two walled garden and courtyard areas with seats and tables for people to enjoy the outside amenities. An activities organiser is employed by the company to arrange and deliver group and 1-1 activities within the home, as well as booking entertainment sessions from outside sources and organising trips into the local community. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are on display in the entrance hall of the home. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 5 Information given by the manager during this visit indicates the home charges fees from £600.00 to £700.00 per week plus the nursing band fee where applicable. The level of fee is dependent on the type of room required and the nursing input needed. People will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available from the manager. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Information has been gathered from a number of different sources over the past 6 months since the service was registered with the Commission for Social Care Inspection, this has been analysed and used with information from this visit to reach the outcomes of this report. The home is currently without a registered manager and whilst recruitment for a suitable individual is taking place the operations manager is standing in. For the purpose of this report the operations manager is referred to as the manager throughout the text. This unannounced visit was carried out with the manager, staff, visitors and people using the service of St Mary’s Care Centre. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with a number of people, visitors and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people living in the home and staff and their written response to these was good. We received 10 back from relatives (50 ), 10 from staff (50 ) and 0 from people using the service (0 ), although it was clear some individuals had contributed to the relative’s surveys. The company completed an Annual Quality Assurance Assessment and returned this to the Commission for Social Care Inspection within the given timescale. St. Mary’s Care Centre registered with the Commission in April 2007 and is classed as a new service. This is the first inspection report for the home and therefore the service cannot be rated higher than a level 3, as it needs to show continuity of practice. The directors and management within the home have worked hard to provide an extremely good service, it has exceeded the minimum standards in aspects of choice of home, environment and staffing practices. What the service does well: The service offers people large bedrooms and living spaces within the home and a good selection of things to do. People living in the home have lots of room to move around and can choose where they want to spend their time. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 7 The home has an enthusiastic team of people working within the service, who like doing their jobs and learning more about how to do it well. The people working in the home want to make sure that the people who live in the home receive good care. All of the people spoken to are positive about the home and like living there. People living in the home and relatives expressed their satisfaction during this visit regarding the care given, service received and the living environment of the home. Staff are hard working and do their best to meet the needs of those people living in the home. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. The home has been built to meet the needs of people who have disabilities and/or who are older in age. The bedrooms, bathrooms and other places that people can use are designed so people can be as independent as possible, but the right equipment is there to help them in their daily care, when needed. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 8 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 Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3,4 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: The statement of purpose and service user guide is given out to people on admission and copies are found in every bedroom. Each of the packs is available in different formats and those seen at this visit included a basic photographic format, a clear print version and one designed specifically for people with dyslexia. Other formats are available on request from the manager. The majority of people and relatives said they received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 10 conditions from the home. One relative said ‘my mother was an emergency admission from another home. The care she receives here is superb and she has not looked so happy and well cared for in a long time’. Four people’s care and records were looked at as part of this visit, they each have been provided with a statement of terms and conditions/contract on admission and these are signed by the person or their representative. These documents give clear information about fees and extra charges, which are reviewed and kept up to date. Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The four files looked at during this visit were for self-funding individuals, and the home’s needs assessment was completed for each person and is comprehensive and includes risk assessments as part of the information gathering process. Discussion with the manager indicated she carries out a needs based assessment on all people prior to admission, and a formal letter offering placement or not is sent out to the enquirer. The home develops a comprehensive care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the person, family and professionals (where applicable) involved in the person’s care. Those people living at the home who receive nursing care undergo an assessment by a registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual. People using the service and relatives are very pleased with the care and support given by the staff, they said ‘the staff are caring and friendly and everyone is well care for’, ‘staff are competent and professional, they are confident in how they give care and show kindness and compassion when dealing with needy people’. Survey responses show that everyone using the service is confident about the care and satisfied that the individual needs of the people living in the home are being met. Relatives said ‘the home has clients of different faiths and disabilities, staff are from different racial backgrounds and they all work as a team’. ‘The staff always have my relative ready for us to take to our bible meetings whatever the time of day, even early morning’. ‘The less mobile people are always included in everything happening within the home, and their special needs are catered for’. Information from the Annual Quality Assurance Assessment and discussion with the people living in the home indicates that all of the people are of white/British nationality, although there are a number of people with different St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 11 faiths and religions. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. Checks of the staffing rotas and observation of the service showed that the home employs male and female staff and a number of staff are from different countries and cultures. Discussion with the people living in the home indicates that they have no difficulties communicating with the staff and that they can express their preferences of staff gender for individuals giving their personal care. The home employs a full time training officer whose role is to ensure that all staff go through an induction before starting work and that an appropriate training programme is in place to ensure the needs of people using the service are met. Information from the files and matrix indicates that the staff have all been assessed and have their own individual training plan with their training needs and goals identified on it. Staff are up to date with their basic mandatory safe working practice training, and have access to a range of more specialised subjects that link to the needs of the people using the service including equality and diversity, care of the dying, wound care, safe guarding of adults (abuse), palliative care, tissue damage and epilepsy management. The employment records show that the manager is using a selective approach to recruitment; ensuring staff have the right skills and attitude to meet the needs of the people living in the home. The home does not have any intermediate care beds and therefore standard six does not apply to this service. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of the people living in the home are clearly documented and are being met by the service and staff. The medication at the home is well managed promoting good health. EVIDENCE: Staff told us in the surveys that they are very satisfied and enthusiastic about the way the home provides them with the information about the needs of the people they support and care for. One person said ‘our records are easy to read and we understand them. We are able to ask the training officer for information on illnesses or diseases to help understand an individual’s needs’. Another staff member said ‘complete and comprehensive information is available for staff to read before a person is admitted to the home’ and ‘the directors and manager are ready to listen to new ideas and requests for additional equipment are met as required’. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 13 Information from the surveys indicates that the majority of people who responded are satisfied that the staff give appropriate support and care to those living in the home. People said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. Comments received were ‘the care staff are supportive and attentive’, ‘they act in a friendly and professional manner’ and ‘communication is good and I am always notified of any changes to my care’. Individual care plans are in place for all people using the service and the four examined set out the health, personal and social care needs identified for each person. The plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. Risk assessments were seen to cover pressure sores, nutrition, moving/handling and activities of daily living. Information about the person’s social interests, likes and dislikes, spiritual needs and wishes regarding death and dying are included within the individuals care plan. People and relatives are able to input to their plan and changes to their care is discussed with the individual where possible. Signatures on the plans show that these have been agreed with the individual and/or their representative. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people and relatives indicate they are satisfied with the level of medical support given to the people living at the home. Entries in the care plans specify where individuals have dietary needs, including PEG feeds, supplement drinks and specialist diets. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. The nurses within the home carry out specialist tasks such as PEG tubes/feeding regimes and wound dressings. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses/beds and seat cushions. People are able to access physiotherapy through their GP and the home also has input from private physiotherapists. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All of the people spoken to prefer to have staff administer their medication. Checks of the medication records showed these are up to date and accurate, including those for controlled drugs and refrigerated items. Relatives commented that they are kept informed of their relative’s wellbeing by the staff; they are regularly consulted (where appropriate) on their care and St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 14 feel involved in their lives. Overall there is a good level of satisfaction with the care being given to the people living in the home. Chats with people revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Individual comments were ‘the staff treat us with dignity and respect, and provide a warm, calm and person centred atmosphere’. Observation of the service showed there is good interaction between the staff and people; with friendly and supportive help being given to assist individuals in their daily lives. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with choice and diversity in the activities and meals provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: The home employs an activity co-ordinator to deliver a programme of events on a Monday, Wednesday and Friday, with evening sessions as and when required. At the moment there is a range of group activities and one to one sessions taking place, which reflect the interests of the people living in the home and also their gender. As the occupancy levels increase the home plans to produce more tailor made activities to suit individual people. On the day of this visit people were playing a game of roulette in the main lounge and looking forward to a film show that evening in the cinema suite. As Hull fair is taking place locally the evening was themed to reflect this with brandy snaps, popcorn and ice cream being offered. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 16 The home offers people a wide range of facilities within the home including a library and music room, which contains a digital piano. Some of the staff and people staying in the home can play this instrument and have enjoyed a number of musical events. Trips out are organised by the activity person and transport is arranged through local companies. Information from peoples’ files indicates that there are a number of individuals who follow different spiritual faiths, including Plymouth Brethren, Judaism, Catholic and Church of England. The manager said that there are regular church visitors (monthly) within the home and people could go to the local church services and religious celebrations as requested. Those of different faiths are able to celebrate their religious festivals, with staff encouraging them to continue following their religious observances and beliefs. The home provides special meals and cakes for birthdays and helps people celebrate all major Christian festivals such as Easter, Harvest Festival and Christmas. Relatives are on the whole very positive about the home and its service. Individuals said ‘on admission people are told to treat St Mary’s as their home and are given numerous facilities to use without pressure to do so’. ‘Independence is promoted and staff support individuals to live their lives in the manner they choose, even where ill health or disabilities may limited their choices’. One visitor said to us that the home offers marvellous living space and staff treat people as individuals; taking care to pay attention to detail and acting on any requests for change in a fast and efficient manner. Visitors and relatives are made welcome at any time and staff are courteous and professional in everything they do. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. The home does not hold any personal allowances for people living there although arrangements can be made if an individual needed assistance and did not have anyone else to help them. Staff have received training around current legislation in equality, diversity and disability matters, so they understand individual rights within the care home and out in the community. People told us that the home encourages them to bring in small items of furniture and personal possessions to decorate their bedrooms. There are meetings where the viewpoints and opinions of those living in the home can be expressed and the management team will listen and take action were needed. Visitors said they are kept informed of any important issues St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 17 affecting their friend/relative and felt that staff did a good job of supporting people to live the lives they choose. Observation of the midday meal showed it to be well prepared and presented, and the kitchen staff had made an effort to provide soft diets in an attractive way. Staff were organised when serving the meal and a number of individuals were seen to offer assistance to people who need help with eating and drinking. People and relatives are pleased with the quality and quantity of the meals served, saying ‘the food is excellent and there is always a choice given’. One individual said that there had been some teething problems with the meal orders, however this has been addressed and the process is much better. A visitor told us that she had asked for more fruit to be given to individuals as part of the menu, and that the next day she observed fresh fruit in bowls throughout the home and this has continued ever since. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with some evidence that people feel that their views are listened to and acted upon. Visitors and people using the service are confident about reporting any concerns and the manager acts quickly on any issues raised. EVIDENCE: Checks of the records in the home show that there have been no formal complaints received since the service opened in April 2007, and that the manager deals with any niggles and grumbles on a daily basis. The home has a complaints policy and procedure that is found within the statement of purpose and service user guide. It is also on display within the home. People’s survey responses showed individuals have a clear understanding about how to make their views and opinions heard and those people spoken to said ‘the manager comes round every day to see us and will discuss any problems at this time’. Relatives are aware of the complaints procedure and are confident of using it if needed. Those who responded to the surveys said that the manager was efficient and effective in answering queries and they were satisfied with her St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 19 actions. One person said ‘on the few occasions that I have raised a query this has been met with understanding, agreement and action’. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of people’s money and financial affairs. Key members of staff have received safe guarding of adult training and the training officer is undergoing in-depth train the trainer sessions so that she can role this out for other staff in the future. All staff have undergone a two-day induction which includes safe guarding of adults information and awareness training, and those staff who completed a survey showed a good understanding of their role and responsibilities of protecting people who live in the home from harm. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 and 26. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within this home is excellent, providing people with a spacious, attractive and safe place to live. EVIDENCE: St Mary’s Care Centre is a newly registered, purpose built care home and the company directors have taken a lot of time to research the design and build of the home, to provide people with a high quality, well finished building incorporating spacious living accommodation and an effective and efficient working environment. The lack of entrance signage can make finding the home a little difficult and discussion with the manager indicated that this was due to the local Council Planning Department not yet agreeing on permission for illuminated signs. Recently an ambulance had not been able to find the home when called out to St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 21 an emergency and staff had resorted to guiding them to the home via telephone messages. The directors of the company are aware of the problems and are working towards reaching an acceptable outcome. Walking around the home it is clear that the environment is spacious, welcoming and decorated/furnished to extremely high standards. People living in the home are very satisfied with their bedrooms and commented on the beautiful interior and exterior of the home. There are four types of rooms available for those wishing to stay in the home. Each is provided with door locks, lockable drawers, an electric profiling bed, a nurse call system, fridge, LCD television, shower/en-suite rooms with ridged grab rails and tiling in different colours so individuals with sight problems can see the aids and adaptations fitted in the room, as they are situated on the deeper coloured sections of the walls. Two of the room styles have patio doors leading into the walled and secure garden and courtyard areas. People in these latter rooms have their own patio furniture to sit on and the nurse call systems in all the rooms are mobile so they can be moved outside with the person and individuals are still able to call for assistance as needed. Corridors and walkways throughout the home are wide enough for people to walk around in comfort and ease, even when they need equipment to aid their mobility. Huge storage cupboards are provided to keep equipment and other products out of bedrooms and communal areas. There are a number of very large bathrooms and shower rooms for general and staff assisted use. These are provided with a variety of lifting equipment including 3 Arjo lifting baths. The home has a wide range of communal spaces including a physiotherapy/treatment room, a library/music room, a cinema room, television lounge and lounges where there is peace and quiet. Visitors/relatives are provided with an overnight stay room when they need to be close to their relative in care. Relatives and visitors have their own kitchen to make drinks and snacks in and staff can use this facility when the main kitchens are locked (night-time). The interior of the home is a non-smoking environment, although people living in the home can enjoy a cigarette in the outside areas. The home has two laundry areas, which have separate clean linen/dirty linen areas. Staff have received infection control training and were observed using this knowledge during their daily practices. The training officer is working with the Infection Control Team to ensure staff practices are as good as possible and reflect the latest legislation and guidance available. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standards of induction and training of staff are very good with staff demonstrating a clear understanding of their roles, ensuring that people using the service are protected from risk and looked after by motivated and knowledgeable individuals. EVIDENCE: Comments from the people using the service, relatives and staff are on the whole very positive about the staffing levels within the home, and individuals feel that there is a high standard of care being given to the people living in the home. Survey responses said ‘the staff are supportive, well trained, helpful and enjoy their work’. Staff commented that ‘things are changing as the home fills up and to date it is working very well’, and ‘as the home increases occupancy the staffing levels are changing accordingly’. At the time of this visit there were 22 people living in the home and staffing levels were as follows: Morning 7am – 8am Two care staff come on for day duties 8am – 2pm Two nurses and four care assistants Afternoon 2pm – 4pm Two nurses on duty and three care assistants 4pm – 9pm One nurse and three care assistants St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 23 Night 9pm – 8am One nurse and two care assistants. Information from annual quality assurance assessment about the number of staffing hours provided, and information gathered during the visit about the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the minimum hours asked for in the recommended guidelines. The home has a full time training officer whose role is to ensure that all new members of staff undergo a two-day intensive induction before they start work. Individual staff members were very positive about the induction and said ‘I had a check list to complete by a certain time’, ‘the two full days covered all mandatory training subjects’ and ‘it is the best induction I have ever done in all my working life’. ‘The nurses shadow a more experienced nurse to become familiar with the routines’. Each member of staff has had one to one time with the training officer to discuss their training needs and future objectives and development. Training plans are in place for all staff and a training matrix shows the overall needs of the team. Staff told us that ‘we looked at all my training needs and agreed what I had to do. I was put in for the training and we completed a form afterwards to see if the session was good’. ‘St Mary’s is still developing and we are developing the training needs as new scenarios and peoples needs arise. There are always training courses available’. Four staff files were looked at and they contained evidence of a variety of training events attended over the past including all mandatory subjects such as moving/handling, fire, infection control, health and safety, food hygiene, and more specialist subjects such as wound care, tissue damage, safe guarding of adults (abuse), nutrition, epilepsy, palliative care and equality and diversity issues. 77 of care staff at the home have an NVQ 2 or above in care and two more staff are in the process of completing this training. Nurses are supported in maintaining their own professional portfolio of practice in order to keep their Personal Identification Number (PIN) from the Nursing and Midwifery Council (NMC) up to date. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 24 and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration audits with the Nursing and Midwifery Council to ensure they are able to practice. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. EVIDENCE: The company had employed a registered manager in time for the opening of the home. Unfortunately this individual left soon after. At present the operations manager is standing in and due to the strong management structure within the company, the lack of a registered manager has not affected the quality of care given to the people using the service, or the support and guidance available to the staff. The company is actively recruiting St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 26 for a suitable person to take on the role as registered manager and is confident that this individual will be in place shortly. The home is working towards achieving Investors in People status and the local Council’s Quality award (QDS), both authorities require at least six months of paperwork before they can assess the service. The manager is completing monthly audits of the service and the registered person has completed the monthly regulation 26 reports, and a copy of these is available for inspection within the home. Meetings for the staff and people using the service are taking place; minutes are kept and are available for any interested parties to read. Policies and procedures are up dated and reviewed as an ongoing practice. Feedback is sought from the people living in the home and relatives through regular satisfaction questionnaires, and the manager has produced a development report as part of this process to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. The home does not keep any personal allowances for the people living in the home so Standard 35 is not applicable in this report. Staff are receiving supervision on a regular basis from their line managers. They are enthusiastic about their jobs and appreciate the support and guidance they receive from their manager. Individuals said ‘I have just had my first supervision with my line manager; it was extremely useful as I hadn’t had much feedback as the previous manager left suddenly. I feel valued and supported in my role and a lot of time and money has been invested in the staff’. ‘Our first supervisions and appraisals have been done, but the nurses and manager are always there to give feedback as and when required’. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, cot sides and daily activities of living. St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 27 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 4 3 4 3 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 Standard No Score 16 3 17 X 18 3 4 X X 4 X 4 X 3 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A 3 X 3 St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 28 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. 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. Refer to Standard Good Practice Recommendations St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Marys Care Centre DS0000070006.V352678.R01.S.doc Version 5.2 Page 30 - 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!