Inspection on 24/01/06 for St Marys Care Home

This inspection was carried out on 24th January 2006.

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

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

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 20/02/07

St Marys Care Home 15/06/06

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 Mary`s Care Home The Old Vicarage Main Street Blidworth Nottinghamshire NG21 0HQ Lead Inspector Karmon Hawley Unannounced Inspection 24th January 2006 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.V277658.R01.S.doc Version 5.1 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.V277658.R01.S.doc Version 5.1 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), Dementia - over 65 years of age registration, with number (23), Old age, not falling within any other of places category (22) St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 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 14/11/05 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. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in two and quarter hours and was performed by one inspector. The main method of inspection 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. Three service users were spoken with and so as to give the inspectors an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The acting manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and the core values and principles in relation to their job role. The focus of this inspection was to concentrate on the remaining core standards not assessed and the requirements made at the previous inspection. What the service does well: What has improved since the last inspection? A new acting manager is now in post and aiming to continue to improve standards within the home. The requirement with regards to covering the exposed pipes has been dealt with ensuring service user safety. Further manual handling training has been arranged ensuring staff have the necessary skills to carry out their job role. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 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.V277658.R01.S.doc Version 5.1 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.V277658.R01.S.doc Version 5.1 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): EVIDENCE: Not assessed during this inspection. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 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): 7,9 Service users health, personal and social care needs are set out in an individual plan of care, however further consideration with regards to complex needs and risk assessments is required to ensure all needs are fully met. Service users are protected by the homes medication policies and procedures and only minor improvements are required to ensure service users are fully protected. EVIDENCE: Service users undergo various assessments such as the activities of daily living, social needs, mental health and cognition, manual handling and pressure area care. Information gained from these assessments forms the basis of the plan of care. Care plans in place were personalised and reflected choices and preferences, the majority were in depth and covered identified needs, however one case file examined did not have assessments completed, a plan of care in place or risk assessments despite this service user having complex needs; another did not fully reflect care and management required for a diabetic service user whilst the final one did not make reference to a pressure sore being cared for by the district nurses. Risk assessments were available however these were brief and again complex needs such as the risk with regards to diabetes mellitus, the use of bed rails and safety with regards St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 10 to wandering were not highlighted. Daily progress notes were maintained and significant events were recorded. There was also evidence to demonstrate the multidisciplinary team is liaised with and visits the home. Service users spoken with stated that their needs were met and they were happy with care received. Staff spoken with were able to discuss service users needs and how these are met. On discussing diabetes one staff member was aware of the signs and symptoms to look for should complications arise, whereas the other was aware of a little information, however felt that should complications arise she would recognise the difference in the service user and would be able to act accordingly. Appropriate medication policies and procedures are in place with the exception of ensuring two signatures are obtained on handwritten entries to ensure these are correct. Medications checked against service users medication charts were correct and corresponded with the prescription. Satisfactory records were maintained. A British National Formulary was available however this was not up to date. Photographic identification was not available for all service users. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 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): 13 Service users are facilitated to maintain contact with family, friends and relevant others. EVIDENCE: There are no restrictions imposed on visiting, which is stated in the homes policy. This policy is discussed prior to service users being admitted in to the home so they are fully informed. 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. Service users spoken with stated that visitors are made welcome and may visit at any time. Staff spoken with substantiated this. The main doors into the home are locked, however relatives may easily leave the building due to systems in place. There are no formal arrangements with regards to local community involvement at present, however the local vicar and entertainers visit on occasion and special events. Some service users also access the town with assistance; one service user spoken with was able to substantiate this. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 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 Service users and their relatives and friends may be confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Relevant policies and procedures are in place with regards to complaints. The acting manager also ensures she talks to service users on a daily basis to ascertain wellbeing and to ensure they are aware that she is approachable and always available. 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. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 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): 19,26 Despite service users living in a satisfactory maintained environment improvements are required in certain areas to ensure service users are fully protected. EVIDENCE: Routine maintenance is carried out when needed. The acting manager has a development plan for the following year, however she was unaware as to whether the provider has any plans. The outside windows are in need of re varnishing/painting as are the iron works and the ramp access from the rear fire exit. The rear fire exit door alarm is currently broken, the door is rotting and the glass not fully secure, due to a service user who wanders this poses a risk. Staff state that they are currently monitoring the service user involved, however a risk assessment with this regard was not available. The laundry room was observed and contained two dryers and one washing machine. There were hand-washing facilities available however the toilet in this room was not in use and therefore there were no sluicing facilities available. Staff stated that a sluicing bucket is used for sluicing soiled linen due to this St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 14 and then emptied into the toilet. Hand washing facilities were available in other areas throughout the home and staff were able to discuss infection control procedures. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 15 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): 28 Service users safety may be compromised due to the lack of an induction programme and National Vocational Qualification Training. EVIDENCE: One member of staff has attained the National Vocational Qualification level two and is currently working towards level three; two other staff members are working towards level two. The acting manager although partway through level three is arranging to commence the level 4 Registered Managers Award as this is more relevant to her job role. An induction programme is available at a recognised level and relevant polices in place, however there was no evidence available to demonstrate this has been utilised. Within one staff file observed a first day induction plan was in place but had not been completed. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 16 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): 31,33 Service users live in a home, which is run and managed by a person of good character who is able to discharge her responsibilities, she now has to undergo the fit person procedure with the Commission for Social Care Inspection to become the registered manager. Despite quality assurance questionnaires being completed information has not been collated therefore it is difficult to ascertain a complete picture of service users views. EVIDENCE: The acting manager has now been in post for two weeks. Previous to this she was a manager within the community for a year, senior carer and care organiser. She had started her National Vocational Qualification level 3 but has now decided to commence level four, as it is more in line with her job role. She underwent an induction prior to commencing and feels supported in her job role. She is up to date with mandatory training and due to experience is aware St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 17 of needs of the client group. During discussions held the acting manager expressed a clear vision of her intentions to improve the home. There was evidence within two case files examined that quality assurance questionnaires had been completed, however the information gained had not been evaluated and collated. There were relevant polices and procedures in place with regards to quality assurance and development however the acting manager was not aware of any plans in place as yet. A requirement set at the previous inspection with regards to the monitoring of water temperatures and a relevant risk assessment had not been completed. The alarm cord in the lounge has not been repaired. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 19 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 15(1) Requirement Ensure that complex needs are fully documented and covered within the plan of care to ensure service users needs are fully met. Ensure service users undergo relevant assessments to ensure needs are identified. Ensure relevant risk assessments for all identified needs are in place with regards to specialist needs for example diabetes and the risk of entrapment with regards to the use of bedrails. Ensure the named service user has an appropriate risk assessment and care plan in place. Ensure the safe administration and recording of medicines. Ensure all service users have photographic identification in place. Arrange for the repair of the rear fire exit door. Arrange for the refurbishment of the outside windows and rusty ironworks. Ensure adequate sluicing DS0000008816.V277658.R01.S.doc Timescale for action 24/02/06 2 3 OP7 OP7 12(1) 13(4,c) 24/02/06 24/02/06 4 OP7 13(4,c) 24/01/06 5 OP9 13(2) 24/02/06 6 7 8 OP19 OP19 OP26 23(2,b) 23(2,b) 23(2,k) 01/02/06 24/04/06 24/03/06 Page 20 St Mary`s Care Home Version 5.1 9 OP31 8(1,a) 10 OP33 24(1) 11 OP38 23 12 OP38 13(4a,c) facilities are in place reduce the risk of infection. The acting manager is required to undergo the fit person process in order to become the registered manager. Ensure quality assurance systems are in place and utilised ensuring the home is run in the best interests of the service users. Ensure the alarm cord in the lounge is repaired. This is an outstanding requirement and must be addressed to avoid enforcement action. Ensure water outlet temperatures are recorded and a risk assessment is in place. This is an outstanding requirement and must be addressed to avoid enforcement action. 24/05/06 24/03/06 24/01/06 24/01/06 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 OP28 Good Practice Recommendations A minimum of 50 of staff employed have attained or are working towards the national vocational qualification. St Mary`s Care Home DS0000008816.V277658.R01.S.doc Version 5.1 Page 21 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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