Inspection on 10/11/05 for St Marys Nursing Home

This inspection was carried out on 10th November 2005.

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 Nursing Home 03/03/09

St Marys Nursing Home 15/04/08

St Marys Nursing Home 09/08/07

St Marys Nursing Home 05/06/06

St Marys Nursing Home 18/04/05

St Marys Nursing Home 26/10/04

St Marys Nursing Home 26/05/04

St Marys Nursing Home 07/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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 327 Main Rd Sidcup London DA14 6QG Lead Inspector Ms Pauline Lambe Unannounced Inspection 10th November 2005 09:45 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 DS0000006772.V259399.R01.S.doc Version 5.0 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 DS0000006772.V259399.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 327 Main Rd Sidcup London DA14 6QG 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) 020 8302 7289 020 8460 7393 St Mary`s Care Home Ltd Mrs Giantee Lallchand Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 20 beds for the general nursing care of people aged 60 Date of last inspection 18th April 2005 Brief Description of the Service: St Marys Nursing Home is registered with the Commission for Social Care Inspection to provide nursing care for 20 Older People. The home is situated on a main road in a residential area of Sidcup close to local shops and bus routes. The detached two-storey house was not purpose built. It has five double and one single bedroom on the ground floor and nine single bedrooms on the first floor. One of the bedrooms has en suite facilities the remainder have washbasins with hot and cold water. Communal areas include a lounge, separate dining room, kitchen and laundry area. Adequate bathing, toilet and sluicing facilities are provided. At the rear of the building there is a garden for residents’ use, which is wheelchair accessible. Visitors can park on the front drive or in the side roads. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.25 hours. The service was last inspected on 26th October 2004. At the time of this inspection the manager was in charge and nineteen residents were in the home. The inspection process included speaking to residents, relatives, staff and management. Records required by regulation were inspected and an inspection of the premises carried out. Compliance with requirements and recommendations made at the last inspection was reviewed. With the exception of medicine management these had been met. Comment cards were left for residents and relatives. Those returned to the Commission indicated satisfaction with the service. What the service does well: What has improved since the last inspection? What they could do better: To ensure residents are not placed at risk improvements were needed to medication management. This was being addressed and the Commission will reassess the changes. To ensure the activities provided are suited to resident’s ability and preference work should continue to involve them with planning the activities. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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 DS0000006772.V259399.R01.S.doc Version 5.0 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): 1 and 2. Adequate information was provided about the service. Residents were provided with contracts for service. EVIDENCE: The home had a statement of purpose and service user guide. As no changes had been made these documents were not reviewed. Copies of the service user guide were seen in resident’s rooms. Contracts for service were seen in files inspected. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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 and 8. Care plans seen reflected the needs of the residents and healthcare needs were adequately met. Concerns remained about medicine management but new systems were being put in place later in November 2005 and will be monitored by the Commission. EVIDENCE: Care plans were prepared and those seen included risk assessments, reflected the needs of the residents and were kept under review. The manager had introduced a new format to record resident’s social history and interests. Records showed residents were registered with a G.P and had been seen routinely by a dentist, chiropodist and optician. Other specialist health services were accessed through G.P referral. Medication management was reviewed at an additional visit made to the home on 6th October 2005. Since that visit the manager had decided to change the medicine system. The new system was due to start at the end of November 2005 and will be monitored by the Commission as to how it complies with regulation. In the meantime the system had been slightly improved so that an audit trail of medicines could be completed. As medicine management was not St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 10 fully inspected a separate inspection will be done once the new system has been implemented. Requirement 1. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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): 12, 14 and 15. From evidence provided improvements had been made to provision of activities. Residents were provided with nutritious and varied meals. EVIDENCE: A programme of activities was displayed in the lounge and staff said they organised activities in the afternoons. A number of residents preferred to spend their time in their bedrooms and a number of other residents were quite frail and not keen to participate with activities. The manager had introduced a new method of recording the activities provided and who took part. The activities included ball games, sing-a-longs, one–to-one time and watching videos. Staff said they encouraged residents to make decisions about their lives but this was not well reflected in care plans seen. Residents who were able to voice their opinions said they were satisfied with the way care was delivered. The kitchen was clean and tidy. Adequate supplies of fresh and frozen foods were seen. A cleaning schedule was in place and records kept of fridge and freezer temperatures. Menus were prepared by the manager on a four weekly cycle and changed three monthly. Those seen indicated a varied diet was provided. Lunch was observed and staff were attentive to residents, assisted sensitively with feeding, and meals were served only when staff were free to St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 12 assist the resident ensuring the meal was taken while still hot. Some residents said they enjoyed their meal and others indicated this by eating all the meal. A full and a part time cook were employed to provide daily and evening cover seven days a week. Recommendation 1. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Adequate procedures were in place to manage complaints and to ensure the protection of residents. EVIDENCE: A complaints policy and procedure was provided and displayed in the entrance hall. Residents and relatives were very clear that if they had a problem they would talk to the manager. Records were kept of complaints made and since the last inspection no complaints had been made to the home or the Commission. Allegations or suspicions of abuse would be referred to Bexley Social Services for investigation. Copies of the Bexley Adult Protection Procedures and ‘alerter’s’ guide were provided. Since the last inspection the manager had introduced a local policy and procedure for the home in relation to adult protection and provided staff with a copy of the DOH document ‘No Secrets’. Staff who spoke to the inspector displayed an understanding of adult protection and how they would manage such an incident. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21,22,24, 25 and 26. The environment was adequately maintained with efforts made to personalise resident’s bedrooms. Bathing and toilet facilities were suited to meeting the needs of the residents. EVIDENCE: Bathrooms and toilets were clean and tidy. Hot water checked was within safe limits. Up to date service records were seen for the hoists, lift and assisted baths. Hand washing facilities were available where waste was handled and staff had access to protective clothing. Bedrooms and communal areas were generally clean and tidy. Bedrooms viewed were nicely personalised. Windows checked above the first floor had restricted openings. Plans were in place to redecorate some bedrooms. The registered provider was seen briefly and said he was hoping to extend the home and upgrade some of the present bedrooms and once plans were finalised he would apply to and involve the Commission with the proposed changes. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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): 27,28,29 and 30. The home adhered to staffing levels agreed by the previous regulatory body. Recruitment procedures had improved to ensure the information required by regulation was obtained when recruiting new staff. EVIDENCE: The staff team comprised of a manager, registered nurses, care assistants and domestic staff who worked together to meet the needs of the residents. Staff rotas seen showed the home adhered to staffing levels agreed with the Commission. Staff said they had access to training and supervision to enable them to fulfil their roles and those spoken with said they liked working in the home and indicated their knowledge of residents and their care needs. Staff were observed interacting appropriately with the residents and offering reassurances where needed. The manager had introduced a system to check that nurses employed were registered with the Nursing & Midwifery Council. Staff supervision was being provided and the system evolving to ensure compliance with standards. Since the last inspection staff had access to training on infection control, fire safety, moving and handling and the new medicine system. One new nurse had been employed since the last inspection and the recruitment records showed that information obtained complied with regulation. Over 50 of the care staff have an NVQ level 2 in care. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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): 32, 33, 35 and 38. The manager was registered with the Commission and assessed as fit to manage the service. Records showed attention was given to providing a safe environment for residents and others. EVIDENCE: Relative or residents meetings were not held. The manager said that she and staff communicate with relatives on a one to one basis. The manager spoke knowledgably about the residents and their relatives. A number of comment cards were returned to the Commission, which indicated satisfaction with the service. The inspector contacted some relatives by phone after the inspection and again they indicated satisfaction with the care, food and environment. Staff meetings were held about six monthly and the inspector was told that at other times staff issues were dealt with as they arose. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 17 Nobody in the home acted as an appointee for a resident. The home looked after some personal allowances for a few residents. This money was provided by relatives and used for resident personal needs. Adequate recording systems were in place and made available to relatives and residents as needed. A selection of safety records were inspected and showed attention was given to providing a safe environment. Equipment and safety systems had been serviced and fire drills had been held at times to include night staff. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 X 3 X X 3 St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 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 OP9 Regulation 13 Requirement The Registered Person must ensure safe systems are in place to manage medications safely. Until the new medicine system is in place efforts must be maintained to improve medicine management. Medicine details entered on administration charts must reflect the details on the pharmacy label. (Timescale of 30/06/05 was not fully met) Timescale for action 16/12/05 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 The Registered Person should continue to work with residents to ensure the activity programme suits their interests and meets their expectations. St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. Extracts may not be used or reproduced without the express permission of CSCI St Marys Nursing Home DS0000006772.V259399.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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