CARE HOMES FOR OLDER PEOPLE
St Mary`s Care Home The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ Lead Inspector
Andrew Sales Unannounced Inspection 14th November 2005 10:00 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 Mary`s Care Home DS0000008816.V266850.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 Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Mary`s Care Home Address The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ 01623 795231 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) Broadoak Group of Care Homes Vacant Care Home 23 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (22) of places St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th February 2005 Brief Description of the Service: St Marys Care home provides personal care and accommodation for 23 older people. At the time of inspection 17 residents were accommodated at the home. St Mary’s Care home is owned by the Broadoak Group that is a company which provides care for older people in Nottinghamshire and some of the surrounding counties. St Marys is a large converted vicarage situated on the main road in the village of Blidworth Nottinghamshire, fairly close to local amenities. All the bedrooms are furnished in a similar style and well appointed, many of these are well personalised. Six of the bedrooms have en-suite facilities. Most of the rooms have views over the rolling countryside. The lounge areas are situated on the ground floor of the home both lounge areas overlook the extensive garden areas. Car parking is available. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted by A.J.Sales on 14 November 2005 at 10.00am. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection?
A majority of the requirements made during the previous inspection have been addressed. As described above, assessments for residents are very comprehensive, with regular reviews being conducted. A number of environmental and health and safety requirements have been addressed to improve the safety of residents. St Mary`s Care Home DS0000008816.V266850.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 Care Home DS0000008816.V266850.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 Care Home DS0000008816.V266850.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): 3,4. Residents are fully assessed prior to entering the home. The home has demonstrated comprehensively, it’s ability to meet the needs of the residents it admits. EVIDENCE: The care plans of three residents, were assessed as part of this inspection. All contained an extended social work assessment, which was obtained prior to their admission. All the files observed contained assessments conducted or reviewed by the current acting manager. All of the assessments were comprehensive and contained detailed information to enable staff to meet the residents assessed needs. Evidence gained from residents confirmed that they felt the home’s care staff and visiting professionals, were well trained and sensitive in their approach. Conversations with residents and their records evidenced that there are a variety of visiting healthcare professionals who provide support and domiciliary services. The inspector also found that the staff demonstrated a good understanding of the needs of residents and had attended a variety of training courses relevant to the needs of older people. The training plans and certificates on staff files also supported this.
St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents are comprehensively assessed. The home is able to meet the healthcare needs of it’s residents. Medication issues are manager appropriately. Residents are treated appropriately. EVIDENCE: All of the residents whose records were checked as part of this inspection had comprehensive care plans. The records show that the plans are being reviewed at least once each month and that residents, and where appropriate their representatives, are being involved in the review process. The acting manager has ensured plans have been brought up to date and are relevant to the current needs of residents. The residents plans also contained risk assessments, which are also reviewed each month. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 10 Residents plans contain details of each residents individual health care needs, including a tissue viability and continence risk assessments. There is evidence that people have been appropriately referred to health care professionals. Care plans viewed contained records of visits by district nurses, General Practitioners and other professionals. The manager stated that they ensure that where possible, the residents can register with a GP of their choice. Staff training records that were viewed, evidenced that medication training was provided for staff responsible for the administration of medication. Self medication assessments are made where appropriate. The home uses the Broadoak group policy and procedure for receipt, recording, storage handling administration and disposal of medication. The home’s medication records were not observed as part of this inspection. Staff were observed during the visit interacting positively with individuals, four residents spoken with, commented very positively on the staff conduct and said they provide a good standard of care. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15. Residents are supported to access daily activities and access the local community. Residents maintain contact with family and friends. Food provided at the home is considered to be acceptable by the residents. EVIDENCE: The inspector observed an activities programme posted on the main corridor wall. The care staff described how the home operates a key worker system in which individual key-workers maintain recorded evidence of daily activities participated in for each resident. Residents spoken with were very commendable about the staff and reported to the inspector that they are provided with a choice in respect of daily routine. Residents spoken with reported to the inspector of their satisfaction with the food provided. The kitchen was observed to be clean and tidy, records were not inspected on this occasion and the requirement set at the previous inspection for menu planning and choices has been addressed. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home operates suitable complaints and adult protection procedures. EVIDENCE: The home has a comprehensive complaints procedure, that meets the National Minimum Standards and which is appropriately displayed throughout the home. Residents spoken with, stated they would raise concerns with the manager and proprietors if necessary. Complaints records were not observed on this occasion. The home has an appropriate Whistle Blowing policy and a policy detailing Adult Protection procedures. The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are all satisfactory. The home has comprehensive policies regarding residents money and financial affairs. One of the two staff members spoken with, had attended training in adult protection and both demonstrated a positive awareness of exposing abuse and bad practice. Training certificates were observed on staff files. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,25,26. The home appeared clean and generally well maintained. Residents spoken with, felt comfortable in the environment. The hot water supplies and exposed pipes and a communication cord need to be addressed. EVIDENCE: The inspector was shown round the home and spoke to a number of residents on the way. The home appeared well maintained and decorated and the residents commented they enjoyed the environment and surroundings. The home employs domestic staff and suitable cleaning schedules are in place. The exposed pipes identified as an immediate requirement from the previous inspection remain outstanding. However the contractors were present on the day and the inspector was informed that this was on their schedule of works. Water temperatures are not regulated and all outlets require regular testing and recording with appropriate risk assessments in place. There is only one communication cord in the second lounge and this was faulty with missing casing.
St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27,29,30. Staff are recruited and employed in suitable numbers. Staff are trained in mandatory subjects required by this standard and for care specific support. EVIDENCE: On the day of inspection there were two care staff and the acting manager on duty, with seventeen people in residence. There are suitable recruitment policies and procedures that were observed as the Broadoak company standard. Three staff files were sampled at random. These contained evidence of applications, interviews, pre employment checks, criminal declarations, confidentiality agreements, evidence of CRB checks and supervision and training plans. The two staff spoken with informed the inspector of various training courses they had attended, which included, adult protection, dementia awareness and mandatory subjects. Of the three staff files examined, they all contained evidence of training in a number of health and safety subjects, dementia awareness, staff supervision and appraisal plans. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 36,38. Staff are appropriately supervised. Health and Safety is generally well managed EVIDENCE: The home operates a standard company induction procedure. The acting manager reported that she supervises and completes appraisal for all the care staff. Records of appraisal were viewed. All staff files contained records of supervision and appraisal. Staff spoken with, also supported this process. The home operates with the Broadoak Group Health and Safety policies and procedures which are comprehensive. Staff training files viewed evidenced staff have undertaken all mandatory training in health and safety. Staff spoken with were aware of health and safety procedures and commented positively on the training provided. Risk assessments are in place for the building and individual service users. Records for Health and Safety monitoring were
St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 16 inspected. All appliances and system servicing (i.e., fire Alarms, lifts, electrical equipment) have been inspected and tested at the appropriate frequencies throughout the last year. One member of staff had not received Moving and Handling training updates at the required frequency. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 17 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 3 X X 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 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 2 X X 2 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X 2 St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 18 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 2 3 Standard 22.6 25.5 25.8 Regulation 23 13 (4,a-c) 13 (4a-c) Requirement Ensure residents alarm cord in the lounge is repaired. Ensure exposed pipes are boxed in or made safe. Ensure water outlets temperatures are recorded and risk assessments conducted at all outlets. …18(1,c,I). Ensure all staff have received manual handling training updates. Timescale for action 30/12/05 14/11/05 14/11/05 4 38.2 13(5) 18(1,a)… 30/12/05 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 Refer to Standard 12.3 Good Practice Recommendations Ensure all residents preferences for social stimulation and recreation are reviewed and acted upon. St Mary`s Care Home DS0000008816.V266850.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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