Inspection on 19/06/08 for St Marys Care Home

This inspection was carried out on 19th June 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

St Marys Care Home 10/02/09

St Marys Care Home 18/09/08

St Marys Care Home 30/10/07

St Marys Care Home 20/02/07

St Marys Care Home 15/06/06

St Marys Care Home 24/01/06

St Marys Care Home 14/11/05

St Marys Care Home 09/02/05

St Marys Care Home 21/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Marys Care Home The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ Lead Inspector Karmon Hawley Unannounced Inspection 19th & 20th June 2008 09:30 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 Home DS0000008816.V366941.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 Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Care Home Address The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ 01623 795231 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), Dementia - over 65 years of age registration, with number (23), Old age, not falling within any other of places category (22) St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes Whose primary needs fall witin the following categories Old age, not falling with in any other category (OP) (23) Dementia - Over 65 years of Age (DE[E]) (23) Date of last inspection 30th October 2007 Brief Description of the Service: St Marys Care home provides personal care and accommodation for 23 older people. At the time of inspection 19 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 garden areas. Car parking is available. The current weekly fees range from £290 - £344 per week depending upon individual needs, these do not include hairdressing and chiropody fees. This information is made available on the point of enquiry. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over two days. The main method of inspection used is called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Three members of staff and two relatives were spoken with as part of this inspection. In addition the views of seven people using the service were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. The registration document was reviewed as part of this inspection to ensure it was correct. No amendments were necessary at this inspection. The Annual Quality Assurance Assessment was not received back until after the visit, therefore this information has not been included in the report. What the service does well: A welcoming atmosphere was evident on arrival and staff were seen to talk freely with people using the service and their relatives. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 6 People using the service said, ‘I am very happy and settled here, I am well looked after,’ ‘it is marvellous here, I am planning to stay here now,’ the staff are very kind and help me when I need it.’ There are a number of activities on offer for people to join in should they wish and people spoken with stated that they enjoyed these. People using the service are enabled and supported to move around the home freely and use the various seating areas around the care home. There are no restrictions on visiting and visitors may be received in private. One person using the service spoken with said, ‘my family visit me often and they are made welcome.’ Relatives spoken with also confirmed that this was the case. A wholesome and appealing menu is on offer, where special diet are catered for. People using the service commended the food. Staff spoken with were able to discuss the health and personal care needs of people using the service and outline how they support them to meet their needs. What has improved since the last inspection? What they could do better: Risk management strategies must be addressed to ensure that people using the service are protected. Plans of care must be developed to ensure that these are in place for all highlighted needs and are up to date at all times. Staff practices, which do not maintain people’s privacy and dignity, must be addressed to ensure that this is maintained at all times. Activities that are appropriate to the needs of less able residents should be developed in order to meet their social needs. To demonstrate that complaints are being dealt with appropriately and effectively, a written record of complaints received by the service must be available for the Commission for Social Care Inspection on request. Additional measures and staff training are needed to ensure that people are protected from the risk of abuse. Staff recruitment practices must be improved upon to ensure that people using the service are protected from unsuitable people being employed. Staff training must be developed and improved upon to ensure that all staff have the necessary knowledge and skills for people using the service. The registered provider must St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 7 The registered person shall give notice to the Commission the name of the person appointed as the acting manager and the intention to register this person as the registered manager, to ensure that service users live in a home that is well run and managed. People using the service and their relatives must be given the opportunity to ensure that their views and opinions are listened to and taken into consideration in the running of the service. An accurate record of all money deposited by a service user or their relative must be kept to ensure that service users personal finances are protected. This 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 Home DS0000008816.V366941.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 Home DS0000008816.V366941.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): 2 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assured that their needs will be assessed and met before they make a decision to move into the home. The service does not offer intermediate care. EVIDENCE: Before a decision to move into the home is made, the regional manager or assistant manager visits people who may wish to use the service within the community. An assessment form is completed before people move into the care home so that staff know what their needs are. Evidence of the assessments taking place was available within the files of those people case tracked. People may also visit the home and spend time there before they make a decision to move into the home. One person spoken with discussed how their social worker had made all the arrangements for them to move into the home for respite care, however they St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 10 were so pleased they had decided to stay at the care home permanently, they stated, ‘I have been here five weeks, it is marvellous.’ Staff spoken with stated that they received all the necessary information that they need when someone moves into the home to ensure that they are able to meet their needs. The service does not offer intermediate care. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs may not always be met in the way that they prefer due to plan of care being task focussed. People are not always protected due to the risk management strategies in place. People privacy and dignity is not always upheld due to the staff practices that take place. EVIDENCE: Information about people’s personal preferences and needs were available within assessments, however this information had not been used within plans of care. Plans of care were mainly task focussed and did not outline this information to make sure that people received their care in their preferred way. Specific plans of care for complex needs such as diabetes mellitus and dementia care needs were not in place to outline how people would be supported and assisted in meeting their needs. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 12 Risk assessments were in place for a number of risks such as wandering, however where one person was using bedrails there was not a risk assessment in place, and within another where bedrails were in use, a risk assessment had only been put into place following an accident. One staff member spoken with was unaware of all the risks of entrapment and the use of bedrails, however the senior carer outlined these to them following the visit. There were also no risk assessments in place for complex needs such as diabetes and challenging behaviour to ensure that people using the service are protected. A requirement was previously set in regard to ensuring risk management plans are in place for all highlighted risks to ensure that service users are fully protected. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. There was evidence of reviews taking place and most plans of care had been updated following these, however there were two incidents where changes had occurred within someone’s care and the plan of care had not been updated to reflect this to ensure consistency. A previous requirement had been set to ensure that reviews are person centred to reflect people care needs and ensure that consistency of care is maintained, this has been part met. Staff spoken with were able to discuss the health and personal care needs of people using the service and they stated that they were able to meet their care needs. People using the service spoken highly of the staff and the care received, one comment being, ‘the staff are marvellous, I am settled and my needs are met.’ There was evidence of people seeing professionals such as the dentist, optician, doctor and district nurse in case files examined. People told us that their health care needs are met as needed; ‘I can see the doctor if I feel unwell,’ ‘I saw the doctor to have health checks when I moved into the care home and ‘ I have just had new glasses,’ During the brief tour of the home pressure relieving equipment was seen to be available for people using the service. Medication record charts were clear and maintained as required. With the exception of one occasion handwritten entries were signed by two members of staff to show that these had been checked as correct so that people receive the correct medication. There were no gaps in signing for medication, demonstrating that people using the service are receiving their medication as prescribed. One staff member spoken with said that they had attended training in medication and they felt confident in the policies employed by the care home. One person using the service was observed to be assisted in an appropriate manner to take their medication by a senior staff member. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 13 Staff spoken with were able to discuss how they ensure that they maintain a persons privacy and dignity, by ensuring that they knock on doors when entering their rooms and by supporting people appropriately when offering personal care. People using the service said that staff were always kind and considerate and confirmed that they knocked on their doors before they enter. We saw staff treat people using the service in a respectable manner, however there was one concern in regard to staff practice and maintaining a person’s dignity and privacy. This arose when a staff member was assisting one person using the service, another person approached them and began talking, the staff member said that she was just taking the other person to the toilet and would be back soon. This person then sat down in the vacated seat and began drinking out of the other person’s cup, which had been left on the table. One person using the service spoken with said, ‘the staff are respectful and listen to me.’ St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are different outcomes for people using the service in that some are content with their life there whereas others would like more activities to offer them stimulation. People using the service receive a well balanced diet. EVIDENCE: Staff spoken with outlined the activities on offer such as dominoes, trips out and gardening. One person was seen to spend time in the garden and when spoken with they said ‘I enjoy it so much out there, keeping it tidy, I spend a lot of time in the garden.’ Several people were also seen to spend time playing dominoes and chatting with each other. However other people using the service were seen simply sitting in their chairs for periods of time not engaged in any form of activity. Two people spoken with said that they would like more to do but they was not sure what they wanted. Another person spoken with said that there were activities on offer but they preferred not to join in. Three people said that the routine of the home was flexible and that they could spend their time as they wished. People were observed to do this throughout the visit and make use of the various seating areas around the care home. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 15 Staff spoken with also confirmed that people are free to do as they please as it is their home and they can make their own choices. Staff said that no one wants to practice their faith at the moment however if they requested this they would be helped to do so. As there is a church next door to the care home people living there can hear the bells when they ring and look onto the church grounds from the garden. One person spoken with said, ‘I have been meaning to go to the church next door but I haven’t got round to it yet.’ So that people using the service are able to maintain contact with people that are important to them there are no restrictions on visiting and visitors may be received in private. People using the service said, ‘we can have visitors when ever we like and they are made welcome,’ ‘my family come to see me and I can go out with them.’ One relative spoken with said that they were always made welcome when they visited and that staff maintained good relationships with them. Staff were observed to maintain professional relationships with visitors throughout the day. People spoken with said that the food was at a good standard and plentiful. One person spoken with discussed the special diet that the staff prepare for them saying that this met their needs. Staff spoken with were able to discuss what constitutes a diabetic diet and the reasons for maintaining this. One relative said that the cook was very good and the meals were at a good standard. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A lack of communication and identification as to who deals with complaints is resulting in these not always being addressed and resolved to the satisfaction of people living in the care home. Although staff stated they were aware of the roles and responsibilities in ensuring that people are protected from abuse, this does not always take place in practice due to lack of communication and investigation into allegations. EVIDENCE: We are aware that the provider has received two complaints since the previous visit, however there was no evidence that these letters had been received, investigated or resolved within the care home. The complaints were in regard to general management of the home, maintenance issues and missing personal items. On speaking with people using the service and their relatives they stated that they felt that they can approach people with concerns, however four different names of contact were given. One relative spoken with said that although they had made concerns known these had not been communicated to the relevant person and therefore had not been addressed. Another relative spoken with said that they had made concerns known to the person in the office at the time and again these were not always addressed. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 17 Staff spoken with outlined the procedures that they take should they receive a complaint, they stated that this would be logged and the management informed. Staff were able to discuss the issues in regard to the missing personal items and this had been logged in their communication book. Despite this being in the communication book, there was no reference as to whether this had been referred to the appropriate authorities or what action was taken. A previous requirement had been set to demonstrate that complaints are being dealt with appropriately and effectively, a written record of complaints received by the service must be available for the Commission for Social Care Inspection on request. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. Staff spoken with were able to discuss what they thought constitutes abuse and the roles and responsibilities that they play in ensuring that people are protected. People using the service offered the following comments, ‘I feel safe and well looked after here,’ and ‘ I am settled and comfortable,’ ‘one person is nasty and lashes out as you walk past, I am scared but I have to put up with it, staff reassure me when this happens as I feel like I am going to snap.’ The appropriate alerts to the safeguarding adults team had not taken place in regard to missing personal items, staff were not fully informed of this process and stated that the management of the home would do this. The requirement in regard to measures must be put into place to ensure that service users are protected from the risk of harm or abuse to ensure that they are fully protected has not been met. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The length of time taken to deal with some maintenance issues affect the way in which people can make their own choices about their life within the home. People using the service live in a clean and comfortable environment EVIDENCE: People using the service offered the following comments about the care home; ‘I enjoy living here in the village location’ and ‘I like living here it is comfortable and kept nice and clean.’ One relative stated that they had requested that maintenance work be carried out in their mothers room, in December of last year, however this has still not taken place to date which is affecting the person using the service being able to use their personal equipment. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 19 Workmen were seen at the care home on the second day of the visit laying a new carpet in the ground floor corridor, as the previous one was stained and dirty. A maintenance book was available; however there were not many entries in this to show that maintenance takes place regularly but there was entries of maintenance logged in a communication book so that staff could address these issues. One member of staff spoken with said that maintenance issues were usually dealt with quickly and if something needed doing urgently they would contact head office to arrange for this to be done. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 20 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): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People using the service are not supported by staff that have been well trained in regards to fully meeting and understanding their personal needs. Although good practices were observed this was then let down by the lack of understanding shown to one person who has dementia care needs. EVIDENCE: Staff spoken with stated that there were sufficient staff available to meet the needs of people using the service and that the staff team worked well together. People using the service spoken with offered the following comments; ‘the staff are very friendly and there are enough staff to help me if I need them’, and ‘the staff are here to help if I need them but I generally look after myself.’ Staff were observed to be available when people using the service required attention. There was a lack of evidence to show that new staff starting work undertake an induction to ensure that they are aware of their roles and responsibilities. One member of staff spoken with said that they did not have an induction when they started at the care home, however they had previous experience, which held them in good stead. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 21 To ensure that staff have the necessary skills and experience to care for the people living at the home 50 of the staff employed have achieved the National Vocational Qualification in care, (a nationally recognised work and theory based qualification) one member of staff spoken with was able to confirm that they had gained this qualification and said that it ensured that they had the necessary knowledge to care for people living in the care home. Staff files examined showed that half of the staff employed did not have references in place to ensure that people living in the home are protected from unsuitable people being employed. One member of staff spoken with was unsure why there were no references on their file as they had supplied these details. There was also a lack of evidence that satisfactory criminal record bureau checks had been obtained for three members of staff and that they were working under supervised practice until these were returned. One member of staff spoken with said that they had received their copy of this back and was not sure why it was not on their staff file. Head office was contacted who was able to confirm that criminal record bureau checks had been received, however these were not at the care home, they were aware that a number of references had not been sent for following our audit and therefore had sent for these. The requirement that had been set to ensure that all the necessary documentation must be obtained before a person is employed by the home to ensure that service users are fully protected has not been met. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. Staff personnel files examined showed that there was a lack of training taking place in mandatory areas, such as first aid, manual handling, dementia care training and the protection of vulnerable adults. Some new staff had not received any training during the time that they have been employed. One new member of staff spoken with confirmed this, however they stated that they had done this kind of work before and felt that they had the necessary knowledge to care for people at the care home. Another member of staff stated that they had undertaken some training, however they felt that more training was needed to enable staff to be fully aware of the needs of people using the service so that these could be met. One person using the service stated that they felt that staff were well trained to meet their needs. Positive staff practices were observed when people using the service were praised for their achievements and enquiries were made in regard to their welfare, however there was one incident when a person who was confused approached a member of staff for assistance when they were told ‘it must be your mind playing up again,’ and there request was not met. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 22 A requirement to ensure that systems are put into place to ensure that all staff have undertaken compulsory training to ensure that they have the necessary knowledge and skills to meet service users needs has not been fully met. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People using the service live in a care home that is currently not managed and run effectively and where they are not given the opportunity to express their views and opinions in a formal manner. EVIDENCE: There is no manager or acting manager in post at present. The regional manager visits the care home on a regular basis to over see the running of the care home. On speaking with people using the service they gave the names of various members of staff who they thought were in charge. One relative spoken with said, ‘the home needs a manager, the residents and staff deserve this for consistency, I do not know who to talk to but there is Gail so I could address issues with her.’ St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 24 Staff spoken with said that they knew who was in charge and who to approach should they need to. One staff member said, ‘I respect the management and the home is well run.’ People using the service and their relatives said that they do not have the opportunity to express their views and opinions in a formal manner and that they did not get the opportunity to complete questionnaires or attend any meetings to have their say about the way in which the care home is run. Staff spoken with also confirmed that people using the service or their relatives do not have the opportunity to do this, however they felt that they were approachable should people wish to approach them. There was no evidence of an annual development programme taking place within the care home to address the issues that require development such as staff training and development and person centred care planning. The previous requirement to ensure that systems must be in place to ensure that service users have a formal method of ensuring that their views and opinions are listened to and taken into consideration in the running of the service has not met. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. The personal allowance of people living in the care home are accessible to them at any time, however on checking these there was a noted deficit in one account, a staff member said that this was because another member of staff had taken some money to purchase an item for the person. On speaking to this person they were unaware that this had taken place and they had not expressed that they required anything. A complaint of the same nature has also been received about another person’s account; again the staff member said that this was to purchase something for the person using the service. They said that it was not normal practice to log when money had been taken but this was always done on return of change and receipts. A requirement was set at the previous visit in respect of ensuring that an accurate record of all money deposited by a person using the service or their relative is kept to ensure that personal finances are protected. Due to this requirement being outstanding evidence of the suspected breach was ceased and further enforcement action is being considered. The hoist and lift certificate were observed to ensure that servicing and maintenance is carried out as required to ensure that people using the service are protected. Some staff have received training in health and safety and they were able to discuss relevant issues such as ensuring that people who may wander are kept safe. There were no obvious hazards observed during the St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 25 brief tour of the home. There were concerns in regard to risk management strategies, which are discussed within standard 7. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X 1 X X 2 St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4,c) Requirement Timescale for action 19/06/08 2 OP7 3 OP7 4 OP10 5. OP12 6 OP16 Risk management plans must be in place for all highlighted risks to ensure that people using the service are fully protected. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. 15(2)(b) Care plans must be kept up to date and reflect the change in needs of residents to maintain their safety. 15(1) Care plans for complex needs such as diabetes mellitus and dementia care needs must be in place to ensure that people’s individual needs are met. 12 Staff practices, which do not maintain people’s privacy and dignity, must be addressed to ensure that this is maintained at all times. 16(2)(m & Activities that are appropriate to n) the needs of less able people should be developed in order to meet their social needs. 22(8) To demonstrate that complaints are being dealt with appropriately and effectively, a DS0000008816.V366941.R01.S.doc 25/07/08 25/07/09 25/07/09 25/08/08 19/06/08 St Marys Care Home Version 5.2 Page 28 7 OP18 13(6) 8 OP18 18(2) 9 OP29 19(1,b,i) schedule 2 10 OP30 18(1,c) 11 OP31 8(2) written record of complaints received by the service must be available for the Commission for Social Care Inspection on request. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. Measures must be put into place to ensure that service users are protected from the risk of harm or abuse to ensure that they are fully protected. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. Systems must be in place to ensure that those staff working with a POVA 1st in place must be adequately supervised to ensure that service users are protected. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. All the necessary documentation must be obtained before a person is employed by the home to ensure that service users are fully protected. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. Systems must be put into place to ensure that all staff have undertaken compulsory training to ensure that they have the necessary knowledge and skills to meet service users needs. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. The registered person shall give notice to the Commission the name of the person appointed as DS0000008816.V366941.R01.S.doc 19/06/08 19/06/08 19/06/08 19/06/08 19/06/08 St Marys Care Home Version 5.2 Page 29 12 OP33 24(1) 13 OP35 17(2) schedule 4 the acting manager and the intention to register this person as the registered manager, to ensure that service users live in a home that is well run and managed. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. Systems must be in place to 19/06/08 ensure that service users have a formal method of ensuring that their views and opinions are listened to and taken into consideration in the running of the service. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. An accurate record of all money 19/06/08 deposited by a service user or their relative must be kept to ensure that service users personal finances are protected. This is an outstanding requirement and enforcement action is now being considered to ensure compliance. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations Plans of care are developed to become person centred to ensure that people’s personal preferences are accommodated. Hand written entries on medication records are always signed by two members of staff to ensure that these are correct. St Marys Care Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Home DS0000008816.V366941.R01.S.doc Version 5.2 Page 31 - 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. 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