Inspection on 01/12/06 for St Marys Nursing Home

This inspection was carried out on 1st December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Marys Nursing Home 20/02/06

St Marys Nursing Home 06/09/05

St Marys Nursing Home 30/09/04

St Marys Nursing Home 05/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St. Marys Nursing Home 1 The Crescent Linthorpe Middlesbrough TS5 6SD Lead Inspector Ann Ferguson Key Unannounced Inspection 1st December 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St. Marys Nursing Home DS0000000207.V322736.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 Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St. Marys Nursing Home Address 1 The Crescent Linthorpe Middlesbrough TS5 6SD 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) 01642 820851 01642 828754 www.bupa.co.uk BUPA Care Homes (GL) Ltd Mrs Jacqueline Elliott Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named individual who is under to age category can be admitted to the home on a permanent basis. That a maximum number of 5 places may be used at any one time for the accommodation of persons who are 55 years and over with a physical disability. 20th February 2006 Date of last inspection Brief Description of the Service: The home is situated in the village of Linthorpe in Middlesbrough. Local amenities including shops, a post office and banks are within walking distance. St Marys is purpose built for elderly people and provides a choice of lounges for the residents and their visitors. The bedrooms are located on two floors serviced by a lift. There are forty-three bedrooms in total, seven of which are double rooms. Three of the double bedrooms have en suite facilities, including a bath. The home fees range from £338 to £510.78 per week. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10am and lasted for six hours. Two inspectors were present throughout. Two residents, two staff members, the nurse in charge and the cook were spoken to during the inspection. House records including individual plans of care, staff recruitment files, medication records, staff training and supervision records were looked at. Also, personal allowance records, health and safety records, and policies and procedures were examined. One relative/ visitor comment card was received and the preinspection questionnaire before the inspection. A tour of the home was carried out. One resident said that all the staff treated her ‘nicely’. A staff member said that the other staff were ‘really good and helpful’. A relative said that staff knew ‘exactly how to handle’ their relative. What the service does well: What has improved since the last inspection? What they could do better: The appointment of an activities co-ordinator is needed for the residents. One resident described their days as being ‘quiet’. Another person spent their time in their room because there were ‘no other activities’. At the time of the inspection, the supervision of staff was haphazard. More regular supervision needs to be provided and recorded. The health and safety checks around window restraints, shower head sterilisation, and wash hand basin temperatures need completing. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 6 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 Nursing Home DS0000000207.V322736.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 Nursing Home DS0000000207.V322736.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 (home does not provide intermediate care, 6) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of records and discussions with staff indicates that evidence is gathered to determine the assessed needs of people before admission. EVIDENCE: The residents have had their needs assessed before moving in to the home. A random sample of individual care plans was looked at. Each had a local authority assessment and also an assessment done by the home. The home has then written up a detailed care plan to support the resident fully. All the care plans sampled had been regularly reviewed and updated to reflect changing needs. St. Marys Nursing Home DS0000000207.V322736.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): 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. The examination of records and discussions with residents and staff demonstrates that staff understand the needs of the residents. There is a sound medication procedure. Staff are aware of the needs to treat residents with respect. The home has suitable arrangements for residents to enjoy privacy with visitors. EVIDENCE: Three individual plans of care were selected at random and all contained thorough care plans. All relevant information and risk assessments were included, covering all aspects of their health, personal and social needs. In one file there was a very good review of the care plan by the home manager. This included a clear action plan for the keyworker to follow through. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 10 Within the plans of care there were a number of other documents that had not been reviewed or kept up to date. For example, the dental records, keyworker’s diary and the relatives’ communication record were not up to date in one resident’s file. In another file some risk assessments had last been reviewed in September 2005. The medication procedure followed within the home is robust. The organisation provides clear guidance for staff to follow. Medication is appropriately recorded, stored, and administered within the home. The medication files were all signed correctly although the files were quite shabby and records were quite loose within them. Medication files are shared for a number of residents. In the front of one folder, confidential information about a resident was found. Information of this kind should be stored in the resident’s personal file. At the time of the inspection, there was one person refusing medication on a regular basis. This was very clearly marked on the medication sheets and was being addressed by group of people involved with the resident. Staff spoken to are aware of the importance of treating residents with respect although a resident did say that staff could be ‘a bit short sometimes’. A relative said that ‘overall the care is very good and sensitive’. It is easy for residents to have visitors at the home, and there is a choice of lounge available for residents to take their visitors in addition to their own rooms. St. Marys Nursing Home DS0000000207.V322736.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. The discussions with residents indicate that they can enjoy contact with other people and they are offered a varied and balanced menu. However, the discussions reveal that insufficient activities are currently available in the home. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 12 EVIDENCE: The pre-inspection questionnaire indicated that a full range of activities was on offer at the home, both within the home and outside. The residents spoken to, however, did not feel that the home matched their social interests and needs. Currently the post of Activities Co-ordinator is vacant and this is a major problem for these two residents. One resident spent their time in their room because there were no activities to do within the home. The other would like to go out but it said that it was too difficult to arrange staff and transport. One resident described their days as being ‘quiet’. The staff spoken to knew that the post was vacant but did not know when it would be filled. There appeared to be no organised activities arranged at all in the home at the time of the inspection. The residents do maintain contact with other people outside the home. Visitors can easily come to the home with no restrictions around time. The residents can make use of their own rooms or the shared lounges, and they are provided with refreshments. Many of the bedrooms are personalised with the resident’s possessions and sometimes their furniture too. Currently none of the residents handle their own finances. The food available was found to be of a very high standard. Following consultation with the residents, there has been a change to the meal arrangements, with the main hot meal being in the evening. Everyone spoken to about this was comfortable with the change. The chef was very enthusiastic about the recent changes with regards to the menus and has done a lot of work with them. There was a lot of choice for breakfast and lunch, and the main meal was different each night of the week. At lunch time the tables were set with tablecloths. Staff are aware of individual needs and preferences highlighted in the plans of care and assist people appropriately with these. St. Marys Nursing Home DS0000000207.V322736.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An examination of the records demonstrates that the home has a robust process for handling complaints. Training of staff in the area of protection is regularly arranged by the home. EVIDENCE: There is a sound basis for handling complaints within the home. Every complaint received by the home is recorded and investigated in a timely and open manner. Appropriate action is taken in all cases. The residents spoken to were clear that they would contact the home manager if they had any problems within the home although neither had taken such action. The Statement of Purpose and Service User guide does need updating with regards to the complaints procedure, to include the name of the Local Authority to which complaints should be directed if the complainant is not satisfied with the home’s response. Training of staff in the area of protection is arranged by the home. Whistle blowing is covered during the induction process, and No Secrets training is provided too. St. Marys Nursing Home DS0000000207.V322736.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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of records indicates that the home has a well-maintained environment which meets the care needs of the residents. A tour of the home shows it to be well-lit, clean and tidy. EVIDENCE: The service provides a homely environment. Residents do personalise their rooms if they wish, and the décor is of a good standard throughout. There is an on-going programme of re-decoration to include bedrooms and communal rooms. Work carried out since the last inspection includes new carpets and curtains to 10 bedrooms, repairs to the kitchen floor, and the re-decoration of the lounge and first floor corridor. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 15 Some work needs to be carried out in three bathrooms, to replace the bath sealant, repair broken tiles, and a bath panel. Also a part of the wall near the staff room is damaged and needs repairing. The home was clean and there were no unpleasant odours. St. Marys Nursing Home DS0000000207.V322736.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): 27, 28, 29, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An examination of staff records and discussions with staff indicates that staff are sufficiently trained to deliver care. Staff receive a lot of training. An examination of staff recruitment shows the procedure to be comprehensive. EVIDENCE: The allocation of staff is appropriate to meet the care needs of the residents. At all times there is a Registered Nurse on duty in addition to care staff, domestic staff, a maintenance worker and an administrator. The home manager works office hours at the home. Very little use is made of agency staff in the home. Senior carers and the Registered Nurses can administer medication within the home. At the time of the Pre-Inspection questionnaire, 63 of all care staff held an NVQ Level 2 or above. The recruitment processes for staff are generally sound. Four staff files were selected and all contained an application form, two written references, a CRB check and a PoVA check. In three of the four files the CRB check was returned after the person had commenced work although the PoVA check was in place. In two of the cases the delays with the CRB were caused by the manager not sending sufficient information with the application. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 17 Induction training does take place in the home. One staff member said she had completed an induction booklet, which was then checked by the home manager. Other training provided included Lifting and Handling, Fire Safety, Health and Safety, Dental Care, Incontinence, Food Safety, Personal Best and First Aid. All the staff files looked at had an individual training plan and an up to date training record within them. Any training dates arranged by the home manager are clearly displayed on a notice board for staff to see. One staff member said that the job seemed quite ‘overwhelming’ at first but now it was OK. St. Marys Nursing Home DS0000000207.V322736.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): 31, 33, 36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An examination of the home’s records indicates that the home has very thorough quality assurance and monitoring processes in place. The home works to a clear health and safety policy and records are routinely completed. EVIDENCE: The manager of the home is suitably qualified, competent and experienced to run the home. St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 19 There are very thorough quality assurance and monitoring systems in place in the home to seek the views of different parties involved in the running of the home. Monthly Regulation 26 reports are received by CSCI and these are very thorough. Accidents within the home are analysed regularly to identify any patterns and care plans are regularly audited by the home manager. The medication systems are audited monthly. Residents meetings take place in the home, and newsletters are regularly sent to relatives/ friends to keep them informed too. Various different groups of staff meet regularly with a senior member of staff to discuss issues within the home. One staff member commented that she liked the staff meetings as it was a way in which she could air her views. Staff at the home get a solid induction into the role with comprehensive training but little evidence was found of ongoing support for staff. Examples of staff appraisals were found in all the staff files that were looked at. No supervision records were found in three of the staff files and only a group supervision was found in the fourth file. One staff member said that she got supervision monthly but another person said she did not get supervision. The health and safety of residents and staff is protected within the home. The pre-inspection questionnaire detailed a number of health and safety checks. These were verified at the inspection and almost all fell within the required timescale. The checks that are outstanding include the window restraints, the sterilisation of the shower heads, and the checking of the wash hand basin temperatures. There is a maintenance man who works regularly in the home and the garden to ensure safety is maintained and the matter of the wash hand basins was raised with him at the time of the inspection. St. Marys Nursing Home DS0000000207.V322736.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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 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 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP8 OP12 Regulation 15 (2) (b) 14 (1) Requirement The manager must ensure that all the information in the plans of care is reviewed and up to date The manager must make interim arrangements for activities within the home until the appointment of an Activities coordinator can be confirmed. The manager must ensure the necessary repairs to the bathrooms and wall near the staff room are carried out. The manager must ensure CRB checks are in place prior to staff starting work The manager must ensure that the regular checks relating to window restraints, shower head sterilisation, and wash hand basin temps are completed Timescale for action 28/02/07 07/01/07 3 OP19 16 (2) (j) 31/01/07 4 5 OP29 OP38 Sch 2 (7) 24 (11) 31/01/07 07/01/07 St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 22 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 Refer to Standard OP9 OP16 OP36 Good Practice Recommendations The manager should arrange for the replacement of medication files to provide secure storage of records The manager should update the complaints procedure to include the local authority. The manager should arrange regular supervision with all staff and record this St. Marys Nursing Home DS0000000207.V322736.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Nursing Home DS0000000207.V322736.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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