Inspection on 20/02/07 for St Marys Care Home

This inspection was carried out on 20th February 2007.

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

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

Other inspections for this house

St Marys Care Home 10/02/09

St Marys Care Home 18/09/08

St Marys Care Home 19/06/08

St Marys Care Home 30/10/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Marys Care Home The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ Lead Inspector Karmon Hawley Key Unannounced Inspection 20th February 2007 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 Marys Care Home DS0000008816.V329577.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.V329577.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.V329577.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 within 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 15th June 2006 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 are £326, these do not include hairdressing and chiropody fees. This information is made available on the point of enquiry. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over course of three hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Five service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were pleased with the staff, care received and the standards within the home. The regional manager and senior staff member in charge assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: What has improved since the last inspection? External iron works and windows have been refurbished to provide a wellmaintained environment for service users. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 6 Further improvements internally are continuing to provide a comfortable environment for service users. A new induction package has been introduced to ensure all new staff are fully trained to carry out their job role. New questionnaires for service users relatives have been devised to assist in the quality review procedures and ensure the home is run in the best interests of service users. 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 Home DS0000008816.V329577.R01.S.doc Version 5.2 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 Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users may be assured their needs will be assessed and met prior to admission. The service does not offer intermediate care. EVIDENCE: The regional manager or the acting manager visits prospective service users in the community prior to admission. Service users may also visit the home. Within case files examined there was evidence to demonstrated that assessments take place and these cover the requirements of the standard. Social worker assessments were also available. Staff spoken with were able to discuss this process and confirmed that this takes place. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in a plan of care, however attention to risk assessments is required to ensure service users are fully protected. Further development is required with regards to service users reviews to ensure they are service user focused to reflect care and condition and ensure continuity of care. Service users health care needs are met. Service users are protected by the homes medication polices and procedures. Service users feel they are treated with respect and their rights to privacy is upheld. EVIDENCE: Three service users plans of care were seen. Service users undergo assessments with regard to the daily activities of living, manual handling, nutrition and pressure area care. Information gained is used within the plan of care. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 10 Plans of care were personalised and support required identified. All highlighted needs were covered and privacy and dignity was fully considered. A risk assessment for falls was within one plan of care, however where there were additional risks with regard to the use of bedrails and where a service user had shown challenging behaviour there were no risk assessments in place. Within one plan of care where a change had occur in a service users mobility the plan of care had not been updated to reflect this. Reviews remain as previous and simply showed the date of when the reviews had taken place, these did not show if there had been any changes with care required. Within two plans of care there were service user profiles available which showed family involvement and past life experiences for staff to consider. Service users spoken with said that staff were very kind and caring and their needs were met. Staff spoken with were able to discuss service users needs and how they support them in meeting these. There was evidence within service users files to demonstrate that the multidisciplinary team and other specialist services are accessed as required. Relevant equipment is gained from the district nurses and during the tour of the home equipment was seen. One service user spoken with stated that the doctor would be called any time needed. Staff spoken with confirmed that these services were readily available. Those service users case tracked medication records were observed, these corresponded with the prescription. Handwritten entries were not signed by two members of staff to show these had been checked as correct. There was evidence available within plans of care to show that service users medication had been assessed as well as service users ability to self medicate. Relevant documentation such as a drugs return book was available for inspection. Service users spoken with said that staff were kind and caring and were respectful at all times. There was evidence within service users plans of care to show that privacy and dignity are respected whilst offering personal care. Staff spoken with discussed how they ensure this is maintained. All consultations are carried out in a private setting. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are assisted to find the lifestyle experienced within the home matches their expectations and preferences, however additional documentary evidence would fully confirm this. Service users are enabled to maintain contact with relevant others, however community links may be improved upon. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: Staff continue to facilitate activities such as sing a longs, bingo and reminiscence with service users as they wish and as time allows. Activities may be on a one to one basis or in a group. Staff spoken with said that they try to ensure activities are available at least once a week. During the inspection service users and staff where having a sing a long, service users when spoken with said that they had enjoyed this. There were no records available to confirm that activities had taken place, however within service users plans of care activities had been addressed. Staff were seen to spend time sitting and talking with service users and there was evidence of good relationships. Both St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 12 staff and service users said that the routine of the home is flexible and service users may choose when they get up and retire to bed and how they spend the day. Service users spoken with spoke highly of staff and one stated that they could have a laugh and a joke and staff remained respectful at all times. There are no restrictions imposed on visiting, both staff and service users spoken with were able to confirm this. Although there is no specific private room there are a range of seating areas throughout the home, which could afford privacy if required. In addition to these areas service users may also use their own rooms or the staff office. One service user spoken with stated that their visitors are always made welcome and may visit at any time. The local vicar visits the home on a regular basis, however staff spoken with said apart form this that there was limited involvement with the community. Service users spoken with stated that they were able to do as they please and they were able to make choices in regards to their daily lives. Several service users were seen to be walking around the home and entertaining themselves as they pleased. Staff spoken with were able to discuss the issues of ensuring service users are treated as individuals and their past experiences and current choices are respected. The regional manager said advocates are not in use at present however this service would be accessed if required. Service users rooms are personalised and they may bring in personal possessions should they wish. The kitchen was clean, tidy and well organised. Relevant records such as cleaning rotas, and temperature control were observed these were completed as required. A wholesome and appealing diet is on offer and choices are given at each meal. Service users spoken with stated that food was at a good standard and choices are offered. The Environmental Health Officer has recently visited the home. Two requirements and one recommendation were made which the regional manager said are being worked towards. The meal on the day of the inspection look well presented and appealing, staff were seen to assist service users appropriately. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relevant others may be assured that complaints will be listened to taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: There have been no complaints received since the last inspection. Service users spoken with were happy with care and expressed no complaints. Staff spoken with were able to discuss the complaints procedure and how they would deal with complaints should they arise. Staff have undertaken training in regard to adult protection and staff spoken with were able to discuss relevant issues and how they would deal with any concerns should they arise. All staff employed had relevant criminal record bureau checks in place. the regional manager said that all policies are updated as necessary at the head office and staff are aware of these. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained environment however to ensure service users are fully protected further attention in regard to hot water delivery is required. The home is clean, pleasant and hygienic. EVIDENCE: The external iron works and windows have been refurbished. New carpets are currently being fitted throughout the ground floor. The ground floor bathroom and toilet are also being refurbished. A room has been converted into a hairdressing salon. The fire officer visited the home June of last year and advised that the regional manager to complete the fire risk assessment. During the tour of the home the inspector tested several hot water outlets, two of these were found to be scalding hot. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 15 The laundry room was observed and contained two dryers and one washing machine. There were hand-washing facilities available. The home was clean, tidy and pleasant throughout despite ongoing refurbishment works. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets service users needs. Staff are working towards ensuring service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are working towards being fully trained and competent to do their jobs. EVIDENCE: The duty rota was observed and demonstrated that sufficient staff are employed to meet service users needs. The skill mix is taken into consideration when planning the duty rota. Staff spoken with said sufficient staff were employed to fully meet service users needs. Service users spoken with expressed no concerns with regards to the availability of staff. The acting manager was not on duty when the inspector visited, therefore access to staff files was unavailable, the regional manager and acting manager visited the CSCI office the following day and brought these in for inspection. Two members of staff have attained the National Vocational Qualification (a nationally recognised performance and theory based qualification) level three and one has attained level two. The regional manager has introduced a new induction programme and all new staff will be undertaking this. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 17 Four staff personal files were seen, two did not have photographic identification, one had no proof of identification and one did not have two references in place, however this was a long term member of staff. The acting manager said she would complete a character reference for this person. Staff spoken with confirmed that they had undertaken criminal record bureau checks. There was evidence that staff training is taking place within staff training files, however it was difficult to ascertain the overall picture of staff training without accessing all staff personal files. Those staff files seen showed that training in compulsory areas is taking place. Staff spoken with said they felt supported in their training and development and said that they had undertaken compulsory training. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no registered manager in post at present; the acting manager who has been employed at the home for fourteen years is running the home. The home is run in the best interest of service users; however further evidence is needed to fully substantiate this. Service users personal finances are safeguarded. The health safety and welfare of service users and staff are promoted however they may not be fully protected due to the noted deficits. EVIDENCE: St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 19 The vacant managers position was discussed with the regional manager. She stated that an ongoing recruitment drive continues; however this position has not been filled. The assistant manager continues to act as the manager with the support of the regional manager. The acting manager has worked at the home for fourteen years. She has attained the national vocational qualification level two and ensures she remains up to date with mandatory training. The regional manager said that she had updated the quality assurance questionnaires, which would be put in the entrance so that relatives may complete these on behalf of service users. These were seen and covered a wide range of outcome areas. The homes policies and procedures are updated on an annual basis. Four service users personal allowances were checked and corresponded with the accounting sheet. Two staff sign for all transactions and receipts are kept. No one at the home is responsible for service users finances. All maintenance certificates with the exception of the yearly gas testing were seen. This was brought to CSCI office the following day. Accident records recorded significant events and contained appropriate information. The fire alarm systems had been tested as required, however the emergency lights had not been tested for three months. Water temperature had not been recorded. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4,c) Timescale for action Ensure relevant risk assessments 20/03/07 for all identified needs are in place with regards to highlighted needs. This is an outstanding requirement since 16/07/06 and must be addressed. Service users reviews are 20/03/07 required to be service user focussed in order to reflect care and condition thus enhancing the continuity of care received. This is an outstanding requirement since 16/08/07 and must be addressed. Documentary evidence of 20/05/07 activities undertaken is required to demonstrate that appropriate activities are offered to service users. The registered person shall 20/03/07 ensure that records referred to in schedule four are available for inspection. Carry out risk assessments on 20/02/07 the delivery of hot water to those outlets that service users have contact with to ensure they are fully protected. All staff employed are required 20/03/07 DS0000008816.V329577.R01.S.doc Version 5.2 Page 22 Requirement 2. OP7 15(1,b) 3 OP12 12(1a,b) 4 OP17 17(2) 5 OP19 13(4,c) 6 OP29 19(1,a) St Marys Care Home 7 8. OP31 OP33 8(1,a) 24(1) 9. OP38 13(4a,c) to have the relevant documentation as listed in schedule 2 in place. This is an outstanding requirement since 16/07/06 and must be addressed. The registered provider shall appoint an individual to manage the care home. Provide further evidence to demonstrate that quality assurance takes place within the home. Ensure water outlet temperatures are recorded and a risk assessment is in place. This is an outstanding requirement since 23/06/06 and must be addressed. 20/05/07 20/05/07 20/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 Refer to Standard OP9 OP12 OP28 OP30 OP38 Good Practice Recommendations Handwritten entries on medication charts are signed by two members of staff to show these have been checked a correct. Develop further community links. At least 50 of staff have attained the National Vocational Qualification. Develop a staff training matrix to clearly demonstrate training that all staff have undertaken. Emergency lights are tested on a monthly basis. St Marys Care Home DS0000008816.V329577.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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.V329577.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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