Inspection on 18/04/05 for St Marys Nursing Home

This inspection was carried out on 18th April 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 10/11/05

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 Road Sidcup Kent DA14 6QG Lead Inspector Pauline Lambe Unannounced 18th April 2005 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 327 Main Road Sidcup Kent DA14 6QG Telephone number Fax number Email 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 Marys Care Home Ltd Mrs Giantee Lallchard CRH 20 Category(ies) of OP 20 registration, with number of places St Marys Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th October 2004 Brief Description of the Service: St Mary’s 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 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 wash basins 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 local roads surrounding the home. St Marys Nursing Home Version 1.10 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. 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, staff recruitment procedures and all windows above the first floor must have restricted openings. For the comfort of residents all bedrooms must have a supply of hot water. To ensure the activities provided are suited to resident’s ability and preference residents must be consulted as to the activities they would like to have included in the programme. St Marys Nursing Home Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marys Nursing Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection St Marys Nursing Home Version 1.10 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 standard(s) 3,4 and 5. Standard 6 did not apply to the service. Residents were admitted to the home based on a needs assessment. Prior to admission relatives and residents were welcome to visit the home, obtain information about the service and decide on the suitability of the service. EVIDENCE: It was evident in the care plans that residents had an assessment prior to admission. Records showed pre-admission assessments were undertaken by a senior member of staff from the home and in some cases by care managers. The registered person confirmed in writing to residents that based on assessment the home could meet their needs in relation to health and well being. Two relatives confirmed to the inspector that prior to admission they visited the home and received written information about the service, which helped them to decide on placing their relative in the home. St Marys Nursing Home Version 1.10 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 standard(s) 7 to 11. Care plans were up to date, reflected resident’s needs and showed how these were being met. Residents and relatives said staff treated them with respect. However the current procedures for management of medicines could pose a risk to residents and need to be reviewed. EVIDENCE: The care provided to three residents was tracked. Risk assessments had been completed and were supported by relevant care plans. Pressure relief equipment was provided and wound care plans in place where needed. There was evidence in some of the care plans to show they had been discussed with the resident and relatives. Daily evaluation records supported the implementation of care plans and care plans were reviewed monthly. Records showed residents were supported to access the services of a G.P, dentist, chiropodist and optician. Other specialist health services were accessed through G.P referral. Terminal care was being provided to a resident and the relatives said they were very happy with the quality of care provided. They said “it is the quality of care that is keeping our relative alive”. Residents spoke positively about the quality of care provided and said staff were kind and treated them with respect. St Marys Nursing Home Version 1.10 Page 10 Staff managed the majority of medicines. The systems in place to record receipt, administration and disposal of medicines were confusing and did not make it possible to do an audit trail of medicines. For example it was not clear when the new stock of medication was started and the number of doses supplied was not recorded on the administration chart. Staff told the inspector that residents managed their own topical medicines. Topical medicines ( creams, ointments etc) were seen in resident’s rooms but there was no record to show compliance with prescription. This situation also applied to a resident prescribed eye drops. The eye drops were kept in the resident’s room, did not have a pharmacist’s label and did not have a date to show when they were opened. No risk assessments had been undertaken to show that resident’s could manage their medicines independently. No record was kept for homely remedies brought into the home and if administered these medicines were not recorded on the resident’s administration chart. All medications were written on the administration chart by the staff. Some entries did not correspond with the detail and information on the pharmacist label and none of the entries were signed. In view of the above medicine concerns it was agreed with the manager that the Commission’s pharmacist would carry out a separate inspection in relation to medication management to offer advice and guidance to ensure medicine management did not pose a risk to residents. Requirement 1. St Marys Nursing Home Version 1.10 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 standard(s) 12 to 14. Residents and relatives expressed satisfaction with the care provided. Meals were served in a relaxed setting. Efforts were made to involve residents and relatives with care planning. Staff should sit down when feeding residents to ensure resident dignity was not compromised. Some residents were not happy with the lack of activities provided and felt the days were very long. EVIDENCE: Residents commented on the lack of activities and stimulation provided. This is an issue that was raised at the last inspection. A programme of activities was displayed in the lounge and staff said they did organise activities in the afternoons. Since the last inspection the manager had attended training in relation to provision of activities and said she planned to cascade the training to the staff team. Residents commented on how much they enjoyed family visits and relatives seen said they could visit when they liked and found staff welcoming and informative. Residents said they were supported to choose how they presented fro example through choice of clothes to wear and hairstyle. Some residents said they did not have a choice about times for going to bed and getting up. Staff gave varied times for when residents went to bed. These varied from resident choice, to after supper and to from 20.00 hours. Based on the comments made it would be appropriate for resident night care plan to indicate their preferred times for going to bed and getting up. St Marys Nursing Home Version 1.10 Page 12 The kitchen and menus were not inspected on this occasion. Requirements made at the last inspection were reviewed and had been met. The cook had attended training on food hygiene and records were kept for fridge, freezer and food temperatures. Residents were seen having lunch and several said they enjoyed the meal. It was evident a choice of meal was available. Staff assisted residents with the meal but stood up when feeding them. Some residents would benefit from having lipped plates or plate guards to enable them to manage their food independently. Recommendations 1 and 2. St Marys Nursing Home Version 1.10 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 standard(s) 16 and 18. An adequate complaints policy and procedure was in place. The home should have its own procedures in place for staff to follow in the event of an allegation or suspicion of abuse. 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 one complaint had been made. The complaint was not upheld. 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. The home did not have its own policy and procedure in relation to adult protection. To ensure staff know how to respond to such a situation the registered person should provide an in-house procedure and a copy of the DOH document ‘No Secrets’. Recommendation 3. St Marys Nursing Home Version 1.10 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 standard(s) 19 to 26. The premises were clean, tidy and adequately decorated. Residents indicated they were content with the environment including their bedrooms. Residents had access to equipment needed to meet their needs. In some of the bedrooms inspected there was no hot water available to the washbasins and this must be rectified. EVIDENCE: The home was clean and tidy with no unpleasant odours. Residents were seen in their bedrooms or the communal lounge. Few residents took their meals in the dining room. Three bedrooms were inspected against the standard. None of the bedroom doors had locks fitted and this was addressed in individual care plans. Bedrooms were adequately decorated and furnished. Rooms contained personal items such as photos, pictures and ornaments. Call bells were working and screening was provided in shared rooms. The hot water supply to a number of washbasins was quite cold. A requirement made at the last inspection about this had not been met. Residents said they were satisfied with their rooms and a number choose to spend their time in their rooms watching T.V, reading or just being private. St Marys Nursing Home Version 1.10 Page 15 One window on the first floor did not have a restricted opening. This was brought to the attention of the manager. Furniture and fittings were domestic in character and since the last inspection new carpet had been fitted to many areas. Bathing and toilet facilities were adequate and since the last inspection had been painted. New impermeable flooring had been fitted to the laundry room. A passenger lift, wheelchairs, zimmer frames and hoisting equipment were provided. Hand washing facilities were available where waste was handled and staff had access to protective clothing. The home’s maintenance and refurbishment programme was not inspected and this will be done at the next inspection. Requirements 3 and 4. St Marys Nursing Home Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. The home adhered to staffing levels agreed by the Commission. Recruitment procedures must be improved to ensure the information required by regulation is obtained for all employees. 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. Training records were not inspected. Staff indicated their knowledge of residents and their care needs. Two employee files were inspected. These did not comply fully with regulation. Information not obtained for the employee included recent photos, verification of references, references from last or current employer and evidence to show a check had been made with the Nursing & Midwifery Council to confirm nurses employed were on the active register. Requirement 5. St Marys Nursing Home Version 1.10 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 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: The manager is registered with the Commission and has the training and qualifications to manage the service. Records were kept as required by regulation and generally well maintained. 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 Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x x x 3 St Marys Nursing Home Version 1.10 Page 19 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 9 Regulation 13 Requirement The Registered Person must ensure safe systems are in place to manage medications. Hand written entries on medicine charts must be supported with two signatures unless signed by the G.P. Medicine details entered on medication charts must reflect the details on the pharmacy label. (Timesclae of 1st February 2005 was not met) Records must be kept for administration of all medicines including topical and homely remedy medicines. Residents who take responsibility to manage medicines must have a risk assessment completed to show they can safely manage the process. A record must be kept for all medicines brought into the home including homely remedies. The medication records must enable an audit trail to be completed for all medicines bought into the home. The Registered Person must Version 1.10 Timescale for action 30th June 2005 2. 12 16 30th June Page 20 St Marys Nursing Home 3. 13 24 ensure residents are consulted about the tye of activities provided to ensure these meet their needs and ability. The Registered Person must ensure risks to residents are identified and as far as possible reduced or eliminated. All windows above ground level must have restricted openings. The Registered Person must ensure that all wash basins in resident bedrooms have an adequate supply of hot water. (Timesclae of 1st April 2005 was not met) The Registered Person must ensure recruitment procedures comply with this regulation and schedule 2. The information required by regulation must be obtained for all employees. Confirmation must be sought to show nurses employed are registered with the Nursing & Midwifery Council. 2005 15th June 2005 4. 23 25 15th June 2005 5. 19 29 30th June 2005 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. Refer to Standard 14 15 Good Practice Recommendations The Registered Person should include resident preferred choice for times of going to bed and getting up in their night care plan. The Registered Person should ensure staff sit down when feeding residents to ensure their dignity is not compromised. Consideration should be given to supplying specialist crockery for residents to help them to manage meals independently. The Registered Person should ensure an in-house policy Version 1.10 Page 21 3. 18 St Marys Nursing Home and procedure is provided in realtion to the management of allegations or suspicions of adult abuse and provide a copy of the DOH document No Secrets for staff. St Marys Nursing Home Version 1.10 Page 22 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent 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 Version 1.10 Page 23 - 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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