Inspection on 19/10/05 for St Marys Nursing Home

This inspection was carried out on 19th October 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 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 21/06/07

St Marys Nursing Home 17/01/06

St Marys Nursing Home 07/09/04

St Marys Nursing Home 26/04/04

St Marys Nursing Home 03/09/02

Similar services:

Byars Care Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Annesley Lodge Care Home

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 Ednaston Ashbourne Derby Derby Derbyshire DE6 3BA Lead Inspector Gail Meads Unannounced Inspection 19th October 2005 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 DS0000002114.V259611.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 DS0000002114.V259611.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address Ednaston Ashbourne Derby Derby Derbyshire DE6 3BA 01335 360254 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) The Hospital Management Trust Miss Kathryn Anne Smith Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (1) of places St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 35 places for OP, E & PD Date of last inspection 7th September 2004 Brief Description of the Service: St Mary’s is a 35-place care home with nursing. The home is able to offer respite and short-term convalescence care. The home is suitably adapted to accommodate wheelchair users. The home provides 24-hour personal care with nursing. Qualified nurses are on duty each shift, and additional management on-call arrangements are in operation outside office hours. Care staff are offered training to levels 2 and 3 National Vocational Qualification (NVQ). Additional in-house and mandatory staff training is provided. The home offers 29 single en-suite bedrooms and 3 shared en-suite bedrooms. The home has a passenger lift between the ground and first floor. Service users have access to large, attractive, well maintained grounds. The building is well maintained. Decoration and furnishings are of a very high standard throughout. The service users have access to a private chapel. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a nine hour period additional time was spent in preparation for the visit, looking at previous reports and other documents. During the inspection process a number of documents were examined, including residents’ care files, staff files and records, time was spent looking around the building and speaking to a number of residents, and to the manager and staff. The inspector spent a specific amount of the inspection concentrating on the care arrangements for the three residents for the purpose of case tracking. What the service does well: What has improved since the last inspection? There is little room for improvement as indicated throughout the report. However the manager continues to develop and improve as an ongoing process. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marys Nursing Home DS0000002114.V259611.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 DS0000002114.V259611.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): 1.2.3.4.5. The manager and staff continue to provide a good administrative structure and information is detailed and easily accessed. EVIDENCE: The homes Statement of Purpose was assessed and found to meet requirements. A full and informative information guide is given to each resident on admission. Three random residents’ files were assessed they contained detailed and comprehensive needs assessments. Residents/Relatives had participated in the process this was demonstrated by the signature on the documents examined, where a relative/resident was unable to participate it was noted on the care plans. The range of information given to residents/relatives enabled them to make positive choices about moving into the home. The respite care facility has now ceased as it is no longer financial viable. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 9 The homes Terms and Conditions of Residency was examined and found to be satisfactory however, there was no Terms and Conditions /contracts found in the Residents information guide nor were they found in the residents’ files. Intermediate care is not provided at this home. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 10 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): 7.8.10.11. Residents have individual Care Plans in place A wide range of health services are available to residents. Residents are treated with respect. EVIDENCE: All residents’ have a general practitioner dental care is provided on a regular basis, ear and eye tests are given as and when needed. Chiropody is provided by both National Health Service and private according to the residents’ preference. Health visits are recorded, as are accidents. Staff were observed talking to residents in a sensitive manner, using the residents preferred address. Residents spoken to spoke of staff being caring, friendly and respectful. One resident said, “The care given here is good I believe this is one of the best homes in the area”. Staff were observed knocking at residents’ doors before entering. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 11 An ‘End of Life decision plan’ is now in place it was examined and found to be satisfactory. The home use Macmillan and Marie Curie nurses are used as and when needed and no resident is left alone during the death and dying process. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 12 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): 12.13.14.15. The home provides a wide range of leisure activities and social events. The residents enjoy a high level of visitors to the home. The Christian ethos of the home is demonstrated by the homes chapel and religious icons situated around the home. EVIDENCE: An activities programme is in place however each resident has their individual social needs noted on their care plan. One resident spoke of enjoying the chapel and the service held there, another resident said. “I had a trip to Ashbourne to do some shopping and my daughter was invited to come with me” she said she had greatly enjoyed this trip out. The home has a designated activities worker for 14 hours a week. The visitor’s book indicated a high level of visitors to the home. Residents spoken to stated that their visitors were always made to feel very welcome, the home has an ‘open door policy’ for visiting times. All the residents spoken to on the day of the inspection stated that they were able to make choices about when to get up and go to bed, residents were able to join in activities as they chose to, one resident said “I know there are activities provided but I do not want to participate in them I have no interest in them” St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 13 The menus were examined and found to be well balanced and varied there was always an alternative meal provided or residents could ask for certain foods if they so wished. The dining areas were small enough to be homely and comfortable, all the tables were laid with tablecloths and napkins, alcohol is offered at meal times if residents request it. The dining areas were warm, light and clean. The atmosphere during mealtime was relaxed and calm, staff offered residents assistance as and when required. Likes and dislike of residents were noted in the kitchen and special diets were catered for appropriately. The food provided was home cooked and fresh fruit and vegetables were always used. The food assessed on the day of the inspection was according to menu. Residents spoken to stated that the food provided was very good one resident said “the foods very good and there are always choices” St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.17.18. Minor complaints are dealt with daily as they occur more formal complaints are dealt with appropriately and promptly. EVIDENCE: There had been one complaint since the last inspection, which had been dealt with to the satisfaction of all concerned and according to the homes own complaint policy, which is displayed on the notice board. A new Complaints policy has been developed and is a much clearer and more accessible document the policy was displayed in the front entrance and is included in the residents information guide. Residents spoken to were aware of the complaints policy and knew who to complain to if needed. All staff have received appropriate adult protection training, records of training are held on the staff files. Staff had supplied two references and had the required medical and police checks carried out prior to commencing their employment. All new staff are given a weeks induction training. The home will assist any resident to gain legal help if required and the home has a comprehensive list of agencies that provide advocacy. All the residents are encouraged to maintain their right to vote the matron stated that 99 had used their postal vote in the last elections. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.23.24.25.26 The home is well maintained internally and externally. The environment is warm, light and clean the furnishings are of good quality homely and comfortable in style. EVIDENCE: A number of residents’ rooms were assessed all contained the required furniture as identified in Standard 24. All the residents’ rooms assessed were personalised and reflected the interests of the residents who occupy them. Items of residents’ own personal possessions were in evidence. The corridor carpets both upstairs and downstairs are in need of replacement as they are showing evidence of wear and tear and have a number of stained areas that deep cleaning is no longer addressing. There are a suitable amount of toilets and bathrooms provided, toilet and bath aids were provided to enable residents to bathe and toilet safely whilst still St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 16 retaining their privacy and dignity. However the rails provided in the upstairs bathroom were not ridged and ‘wobbled’ which could potentially cause unsteadiness and an accident. The upstairs shower did not have an accessible call cord for the toilet. Communal areas are spacious warm and clean. Wheelchair access is provided throughout the home and there is a shaft lift provided. Residents can access the extensive garden and park areas around the home. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 17 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): 27.28.29.30. Staffing levels are maintained at a high level to meet the identified needs of the residents. Staff are well trained and skill mix is taken into consideration when duty rotas are prepared. EVIDENCE: The staff rotas were examined and found to reflect the assessed needs of the residents this is demonstrated by the staffing levels increasing when there are residents with high dependency needs in residence. All staff have received their mandatory training and there is a very comprehensive induction process in place. Three staff files were assessed and found to contain the documents as required in Schedule two of the National Minimum Standards and had been in place prior to the commencement of their employment. The files were well organised and information was easily accessed. The homes recruitment process was adhered to according to the homes recruitment policy. Staff have very good training opportunities provided and this is reflected in the very high number of staff who have achieved National Vocational Qualification (NVQ) at level two and three. Staff files examined had a personal training and development programme in place, the training provided for staff is very comprehensive. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 18 St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.35.37.38. The matrons’ style is open providing good communication channels to residents, their relatives and to staff members. EVIDENCE: The matron is appropriately trained and has a number of years experience in the caring profession, she presents as competent and confident. There are no bank accounts held by or for residents in the home. Any extra costs incurred by residents are purchased through petty cash and invoiced monthly to the relatives. A number of records were examined during this inspection including, menus Care Plans, reviews, staff files, risk assessments, accidents, complaints and residents’ financial transaction all were found to be satisfactory. The residents’ files indicated that risk assessments had been completed including nutritional scoring, pressure sore, falls and moving and handling. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 20 A locked door was found to have the key in the lock, which could have given residents access to a number of hazardous substances stored in this area. Accidents are monitored and reviewed monthly and actioned accordingly. The service certificates for the homes gas supply and boilers, electrical appliances, hoists shaft lift, disposal of waste and water tests were examined and found to be satisfactory. St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 21 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 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 4 x 4 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x 3 2 St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 22 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 Standard OP19 Regulation 23(2)(b) Requirement The registered person must ensure that the corridor carpets are replaced due to wear and staining. Timescale for action 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Marys Nursing Home DS0000002114.V259611.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000002114.V259611.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!