Inspection on 14/03/07 for St Marys Continuing Care

This inspection was carried out on 14th March 2007.

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

The inspector 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 Continuing Care 20/02/06

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE St Mary`s Continuing Care St Mary`s Continuing Care Ltd Penny Lane Collins Green, Burtonwood Warrington Cheshire WA5 4DS Lead Inspector Anthony Cliffe Unannounced Inspection 08:30 14 , 15 and 16 March 2007 th th th X10029.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 Continuing Care DS0000063421.V330994.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 and Care Homes for Adults 18 – 65*. 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 Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Continuing Care Address 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) St Mary`s Continuing Care Ltd Penny Lane Collins Green, Burtonwood Warrington Cheshire WA5 4DS 01925 294850 01925 294855 St Marys Continuing Care Ltd Care Home 63 Category(ies) of Dementia (21), Dementia - over 65 years of age registration, with number (20), Mental disorder, excluding learning of places disability or dementia (11), Mental Disorder, excluding learning disability or dementia - over 65 years of age (11), Physical disability (11) St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 63 service users to include:* Up to 20 service users in the category of DE(E) (Dementia over the age of 65) * Up to 21 service users in the category of DE (Dementia under the age of 65) * Up to 11 service users in the category of PD (Physical disability under the age of 65) * Up to 11 service users in the category of MD (Mental disorder excluding learning disability or dementia under the age of 65) or up to 11 service users in the category MD(E) (Mental disorder excluding learning disability or dementia over the age of 65) 20th February 2006 Date of last inspection Brief Description of the Service: St. Mary’s care home with nursing is a purpose built two-story building comprising of 63 single bedrooms with en-suite toilets/shower facilities. The four units are separate from each other and have their own manager. Each unit has its own dining and lounge facilities. There is a separate activities room and therapy room. The external grounds are landscaped and secure. St. Mary’s care home was registered on 8th September 2005. It is located in the Collins Green area of Burtonwood in Warrington. It is on a local bus route and close to the railway stations at Earlstown and St.Helens Junction. Fees range from £390 plus free nursing care contribution to £1840 per week. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on the 14th, 15th and 16th March 2007 and lasted 20 hours. A Regulatory Inspector carried out the visit. This visit was just one part of the inspection. Other information received was also looked at. Before the visit the home manager was also asked to complete a questionnaire to provide up to date information about services provided. Questionnaires were provided for residents, families, and health and social care professionals to find out their views. During the visit various records and the premises were looked at. A number of residents and staff were also spoken with and they gave their views about the service. One requirement remains outstanding from the previous site visit. What the service does well: St. Mary’s provides a range of services for residents with differing needs. The standard of equipment and décor of the home provides a clean and comfortable environment for residents. Questionnaires received from residents and relatives prior to the site visit said the standards were excellent Prospective residents have a full assessment prior to admission and written information is provided for them. Care plans are completed to a good standard on the units. A variety of social activities are provided for residents. There are separate facilities for activities and physical exercise. There is a generous budget for each unit to provide activities. Staff are friendly and approachable and residents and relatives comfortable in approaching staff for information or help. Care is of a good standard and residents look well cared for and comments from residents and visitors support this. The manager and staff communicate well with residents and visitors and visitors said they are kept informed about their relatives. Requests or concerns are responded to positively. The health and safety of staff and residents is provided for. The owner provides residents with additional health and social support by employing St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 6 healthcare professionals qualified in social care, mental health, neurology and physiotherapy. What has improved since the last inspection? What they could do better: An application for registration as manager must be submitted so residents will be confident a competent and suitable experienced manager manages St.Mary’s. Additional facilities should be provided to support residents develop and maintain their independence in daily living skills. The recruitment of staff needs to improve to ensure residents are protected. Additional staff/hours should be made available so the staff induction/training programme is ongoing and ensures staff receive relevant training to meet residents’ needs. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 7 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 Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available for residents and their representatives so they can make a choice about where they live. Residents’ needs are assessed prior to moving in so appropriate care can be provided to them. EVIDENCE: St. Mary’s accommodates mainly people from the Warrington area and is welcoming to anyone from outside the area or with a disability, different ethnic or cultural needs or sexual orientation. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 10 Residents or their relatives were provided with a copy of the service users’ guide and statement of purpose on request and copies of this and the most recent inspection report were available in St.Mary’s. This contained Details of the facilities and services provided to residents. Information could be provided in different formats on request to head office. Survey’s returned from residents prior to the site visit confirmed that they had received information on St.Mary’s that helped them or their relative to choose to live there. Seventeen out of twenty five surveys said residents had information that helped them to choose St.Mary’s. A relative said, “ We looked at other homes but this was the best. It was a godsend getting him into here, the place is wonderful and so are the staff. The facilities and food are first class”. Four files were examined of residents who moved into St.Mary’s. The residents had met with the manager or registered nurse to discuss their care prior to moving in. Information was gathered and this was recorded using a list of daily activities of living. This included information on their physical and mental health but did not have specific areas to record the differing needs of residents such as assessment of acquired brain injury, mental disorder and dementia. The record used to record information did not allow staff to record a lot of information and the acting manager and clinical director said this was to be revised. Copies of these documents were on residents’ files. Copies of social workers assessments and care plans were on file with information from the NHS hospital the residents were staying at. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed records of care, liaison with health and social care professionals and good medicine management ensures residents’ health and welfare needs are met. EVIDENCE: The care files of four residents were examined due to the different needs of residents within the four units. Each care plan had a pre admission assessment of physical and mental health and an assessment by the social worker or nurse St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 12 assessor. From looking at care plans, observing staff working practices and talking with residents, staff and the health needs of residents were met. There were good examples of care plans in place that monitored residents’ health. Care plans were in place to monitor eating and drinking, risk of developing pressure ulcers, assistance with personal care, managing mental health and aggression where just some examples. Good practice in routinely monitoring residents’ physical health was in place to monitor residents’ blood pressure and weight. Risk assessment and risk management plans were in place to monitor the use of bed rails and dealing with challenging behaviour. Positive outcomes were recorded in reviews of risk management plans with levels of aggression recorded as reducing for several residents. The risk of entrapment of limbs was identified in the risk assessment of bed rails but the document used to record this could be more detailed to record relevant guidance. The clinical director verified the care planning documents were changing and the previous manager had developed new draft documents, which had not been returned to St.Mary’s when she unexplainably resigned. The owner has contracts with healthcare professionals including consultants in psychiatry and neurology to provide weekly clinics at St.Mary’s. A physiotherapist is also employed. Residents can keep their own General Practitioner (GP) but a local Warrington GP provides a service to St.Mary’s. The GP for St.Mary’s returned a General Practitioner comments card prior to the site visit and recorded ‘ A truly well organised place. Excellent service to patients all round. Well done’. Medicines management and administration was examined. No errors were noted on medicine administration records. A monitored dosage system was used throughout the care home. The acting manager and clinical director manager audited medicines as part of the quality assurance system. Information was available for registered nurses on the side effects of medicines used. During the site visit a new method on gathering the experiences of residents was used. A small group of residents who could no longer used words or communicate their needs were watched for a period of two hours. Information on how they related to one another, staff, pets and their environment were recorded. This included staff interaction and practice. The findings of the observation were that there were positive interactions between residents, residents and staff and social interactions. One resident was sleeping for the majority of the two hours but examination of their care records recorded underlying physical health problems as the reason for this. Staff practice was very positive but there was an occasion when an agency staff did not uphold the dignity of a resident. The incident was discussed with the acting manager who agreed to speak with the staff member concerned. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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. Residents are supported in making choices about their lifestyle but the provision of facilities to support their independence could improve so they have more control over their lives. EVIDENCE: St. Mary’s employs an activity coordinator and has dedicated facilities for the provision of activities. Details of what activities available were displayed in the entrance and on the units. Residents said there were a variety of planned activities available to them. Social activity care plans were in place and life St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 14 histories completed for some residents by their families. Residents talked about their daily lives and choices they made. Activities taking place during the site visit included pets for therapy where a dog from pets for therapy was brought in to meet residents. There was a coffee morning on a unit and outing to the local pub. There were details of local clergy visiting residents each week. The home has its own therapy room and gym. The owner also employs a physiotherapist to gather information on residents’ health, provide treatment and exercise programmes. Residents care records contained a health check by the physiotherapist for exercise programmes. A resident who recently moved into St.Mary’s had his own television and video player. He said he had daily newspapers and his family had brought in videos for him to watch. He said he was aware of the activities and once he felt physically well he would join in. He said he enjoyed the food and had put on weight. Another resident said that staff at St Mary’s respected her culture and were aware of her needs but she did not have access to a kitchen were she could prepare meals from her country of origin. She said, “ The cook has information on what I like to eat. I enjoy fish and chips but don’t always get the meals I ate in my own country. If I could use the kitchen I could cook for myself. I have the chance to go out regularly with staff to get my hair done and I can use the laundry to wash my clothes. They keep records on me and I can read them”. Another resident said, “ I moved in a few weeks ago and have settled very well I have my favourite carer but don’t need a lot of help. I go home most days and spend a lot of time with my family. The food is good and more choice would be nice for me. I can cook for myself but we only have a microwave and I don’t eat processed food. I like chicken jalfrezi and can cook that and would like to”. A survey returned by a relative recorded ‘more outside activities, maybe getting dad more involved in chores such as washing up or laundry and gardening’. Twenty-two residents surveys were returned prior to the site visit and these recorded that activities were always or usually arranged. The clinical director and acting manager confirmed that a bathroom that is not used is to be refurbished into a kitchen for residents to prepare their own meals and as a facility to help residents regain daily living skills. An additional activities coordinator was also planned to be recruited. Visitors were seen throughout the day. Staff offered visitors the option to use the quiet lounge and a drink when they arrived to visit a relative. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 15 Breakfast and lunch were seen being served. Residents had the choice of a cooked breakfast or lighter option. Residents were able to choose their meals. Menus were on display to inform residents of the alternative choice. The menus had been revised to include symbols to represent the different meal times. Menus informed residents of the choice of meals available. Twenty-two residents’ surveys were returned prior to the site visit and these recorded residents always or usually enjoyed the meals provided. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information was available to guide residents and relatives on how to make a complaint and who to make it to. There were procedures and guidance available for staff to ensure that residents are protected from abuse, harm and poor practice. EVIDENCE: There were no recorded complaints since the last site visit. Twenty-two residents’ surveys were returned prior to the site visit and recorded that residents knew how to make a complaint or who to talk to if they had concerns. Prior to the site visit a staff member raised a number of concerns about how St Mary’s was managed. These concerns were discussed with the owner prior to the site visit and discussed with the clinical director during the site visit. No evidence was found to support the concerns raised. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 17 A referral under the local council adult protection procedures had been made by St Mary’s. St Mary’s cooperated with the local council in the investigation of the allegations made against a staff member and suspended the staff member concerned. On completion of the investigation St Mary’s took the appropriate disciplinary action against the staff member and informed the relevant agencies of their decisions. The local council commended St.Mary’s for the prompt action and cooperation taken in this matter. Staff had received training in managing challenging behaviour as a number of incidents had been reported under the relevant regulations. Staff interviewed were aware of how to diffuse potentially aggressive situations using nonphysical approaches. A resident’s care plan recorded how their aggressive behaviour had lessened. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 excellent This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable and well maintained environment, which is equipped to meet their needs. EVIDENCE: All bedrooms were single with en-suite toilet and shower facilities. Residents could personalise these as they wish. All bedrooms had an electrical profiling bed as standard. The décor and furnishings in St. Mary’s is of a high standard and finished with soft furnishings, paintings and electrical equipment. In the St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 19 dementia care units there were orientation boards to assist residents in recognising the day, date, time of year, staff on duty and choice of meals available at meal times. The dementia care units had not introduced ‘memory boxes’ outside residents’ bedrooms in which they could display photographs and mementos but had put residents photographs on their bedroom doors. All areas of the building were clean and hygienic. Residents and relatives surveys returned prior to the site visit said there was a very high standard of house keeping and cleanliness at St Mary’s. A resident described the standards as “Like a four star hotel”. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 adequate This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are adequate to meet residents’ needs. Staff recruitment needs to improve to ensure that residents are protected. The induction and training programme needs to be ongoing to provide a skilled workforce that protects residents’ welfare. EVIDENCE: Staffing levels were appropriate and the acting manager confirmed that staffing numbers were determined by the dependency of residents and could change. Each unit had an appropriate mix of qualified and unqualified staff. The clinical manager on each unit was experienced in the care of the residents for that unit. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 21 The pre inspection questionnaire returned prior to the site visit recorded that sixteen of the thirty-five care staff employed had an NVQ level 2 qualification. The training co-ordinator was on long-term sick leave at the time of the site visit and the acting manager and clinical director could not confirm how many staff were enrolled on an NVQ level 2 qualification. St. Mary’s had detailed policies and procedures regarding recruitment. The procedure included an equality and diversity policy. Staff were employed in line with the General Social Care Council codes of practice, and signed a contract, which includes a statement of their terms and conditions. Prior to the site visit the acting manager and clinical director informed CSCI under the relevant regulation that they had temporarily suspended two staff on full pay on discovering they had been employed by the previous manager without completing a Criminal Records Bureau (CRB) disclosure. In examining staff records, discussions with recently employed staff and administration staff it was found that other staff had been employed without the required procedures being followed. Two staff verified the previous manager had telephoned them to confirm they could commence employment. Their staff records did not contain two references. Another registered nurse had been employed without two references being received. Administration staff confirmed the responsibility for coordinating recruitment records had been taken from them by the previous manager. The acting manager had reversed this decision. The acting manager and clinical director had audited staff files and found others without employment references. They had written to referees for outstanding references. St. Mary’s employs a training and development co-ordinator. He was not present at the site visit due to long-term sickness. Three staff were interviewed about their induction. Two staff verified they had not completed an induction programme but had been shown around the building, fire exits and alarm points. They had not had fire training only recently being appointed. Training records were not up to date and the induction programme for the third staff member was not on file but he confirmed he had a day with the training co-ordinator. He said, “ He explained what to do in case of fire and we looked around the building. This lasted three hours. He gave me a staff handbook. I then worked under the supervision of the trained nurse and we went through the rest of the handbook. This lasted a few weeks. I met the trainer a few months later to chat about how I was doing”. Records were kept regarding training and qualifications, but a training and development matrix was not available during the site visit. The pre inspection questionnaire and staff training records available confirmed that staff had completed mandatory training other than new employees. In the training co-ordinator’s absence no training or induction had taken place. The pre inspection questionnaire recorded staff had training in moving and handling, care and responsibility (dealing with aggression), care planning, basic food hygiene and NVQ qualifications at levels 2, 3 and 4. Staff St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 22 interviewed confirmed they had completed fire training, care and responsibility, understanding acquired brain injury, induction for NVQ level 2, fire marshal training, HIV and Huntingdon’s disease. Registered nurses interviewed said the clinical director had discussed further training in mental health for them. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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 good. This judgement has been made using available evidence including a visit to this service. The home is well managed and residents views are taken into account so they have an influence in how the home is run. The practices in the home ensure that residents are safe and their welfare is promoted. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 24 EVIDENCE: Since the last site visit the manger appointed in December 2006 had resigned and one of the lead clinical nurses appointed as the acting manager. The acting manager is a registered general nurse in and had been employed at St.Mary’s for over a year. There was also a clinical director appointed in 2006. He had line management responsibility for the manager at St.Mary’s. Prior to the site visit the owner confirmed that the previous manager had resigned suddenly without notice. Following this a number of serious concerns were raised about how St. Mary’s had been managed. The clinical director confirmed this included the recruitment of staff, development of records, policies and procedures and records required by CSCI. The acting manager and clinical director had taken appropriate action on discovering a number of concerns. This included suspending two staff members, obtaining a copy of the certificate of registration for St.Mary’s and duplicate pre inspection questionnaires. Staff interviewed said they were well supported by the management team and the owner. Staff said the owner visited regularly and talked to residents and staff about how St.Mary’s was managed. Staff said that residents were well cared for and regular residents’ meetings were held to gain their views about things. Social activities were highlighted as being good. Staff said each unit received a generous monthly budget, which if not spent was not reduced the following month. There was a quality assurance system in place, which comprised of the acting manager and clinical director completing monthly audits. These included monthly audits on accidents, pressure ulcers, safety equipment, medicines, health and safety checks on the building, housekeeping and care planning as some examples. The clinical manager then produced a report for monthly board meetings which reported on the quality assurance system, costs, staff sickness, quality of food and admissions to St.Mary’s. Quality assurance included residents meetings to gain their views on how St.Mary’s was managed. An example of this was that residents disagreed with kitchen staff taking a short cut through one of the units when serving meals to other areas of the building. The manager had confirmed that this practice would stop and residents’ rights upheld. Monies held on behalf of residents were managed safely and securely. Information provided by the provider in a pre inspection questionnaire and records held on site were examined. All the required maintenance and health and safety checks of the building and equipment had been completed. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 25 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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 4 20 X 21 X 22 X 23 X 24 X 25 X 26 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 OP29 Regulation Requirement Timescale for action 14/03/07 19(1)(a)(b)(c) The registered person must not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. (Timescale 20/02/06 not met) 8(1) The registered person must ensure that an application for a suitably qualified and experienced manager is submitted to the Commission for Social Care Inspection. 2. OP31 01/03/08 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 OP12 Good Practice Recommendations Additional facilities should be provided to support residents DS0000063421.V330994.R01.S.doc Version 5.2 Page 27 St Mary`s Continuing Care 2. OP30 develop and maintain their independence in daily living skills. Additional staff/hours should be made available so the staff induction/training programme is ongoing and ensures staff receive relevant training to meet residents’ needs. St Mary`s Continuing Care DS0000063421.V330994.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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. 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