Inspection on 20/02/06 for St Marys Nursing Home

This inspection was carried out on 20th February 2006.

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 01/12/06

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 Val Daly Unannounced Inspection 27th February 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.V272854.R01.S.doc Version 5.1 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.V272854.R01.S.doc Version 5.1 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.V272854.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named individual who is under the 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. 6th September 2005 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. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10am and lasted for two hours. Three residents, the nurse in charge and the administrator were spoken to during the inspection. Numerous records including staff recruitment files, medication records, staff training, personal allowance records, policies and procedures were examined. A partial tour of the home was carried out. Three residents were spoken to during the inspection; one commented that ‘all the staff are friendly and polite’. Another resident described how she preferred to stay in her room and staff regularly ‘popped in’ with meals and drinks and to see if she needed anything. What the service does well: What has improved since the last inspection? What they could do better: St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 6 The home should continue to develop the service and maintain standards of care. 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 DS0000000207.V272854.R01.S.doc Version 5.1 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.V272854.R01.S.doc Version 5.1 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): EVIDENCE: These six standards were not assessed at this inspection. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 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): 9 & 10 The homes procedures for storing and administering medication are robust to safeguard the residents. Arrangements are in place to help preserve resident’s privacy and dignity. EVIDENCE: Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. Examination of medication administration records showed that the procedures were being followed. Risk assessments were in place to be completed for any residents who wished to self medicate. However at the time of the inspection there were no residents who managed their own medication. Three residents were spoken to during the inspection. Two said that they mostly preferred to stay in their bedrooms and that staff ‘popped in often to make sure they were ok’. Staffs always knock on their doors first, ensuring privacy is maintained. Another resident preferred to spend his day in the lounges and said he found the staffs were always friendly and pleasant. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 10 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): 13 & 14 Good contact is encouraged and maintained between family, friends and the local community. Residents are encouraged to make positive choices about how they spend their day. EVIDENCE: Three residents said that friends and family are welcome to call at any time and can visit in their bedroom, one of the lounges or dining room. Residents are involved in the local community as they wish and there are social events at the Community Centre. There is also a Theatre close by and some residents attend the pantomimes and other productions there. At the previous inspection it was noted that the menus did not state the alternative food available if the resident did not like the meal offered. New menus have since been put in place, which show alternatives meals available. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 11 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): EVIDENCE: These three standards were not assessed at this inspection. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: These eight standards were not assessed at this inspection. At the previous inspection it was noted that some of the water temperatures for baths and a shower were too cold. Also the six monthly maintenance plan for checking the temperature in the wash hand basins in the residents’ bedrooms was not up to date. On examination of the maintenance records water temperatures recorded were within acceptable limits and the testing was up to date. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 13 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 The procedures for the recruitment of staff are robust. The deployment of staff on all shifts is appropriate to ensure that residents are supported by an experienced group of staff. EVIDENCE: When completing the rotas the manager balances out the more experienced and qualified staff with junior staff. The home has a policy and procedure in place for the recruitment of staff. Staff records showed that the required information, references and CRB checks were in place prior to staff commencing work in the home. A training programme for staff is in place. Since the previous inspection staff had undertaken training in many areas such as NVQ 2 and 3, Adult Protection, Fire Safety, Infection Control, Health and Safety and Dementia Awareness. The home have more than achieved the required number of care staff to have completed NVQ training, At the time of the inspection 80 of care staff had completed NVQ level 2 or above. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 14 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, 33 & 35 The manager offers leadership to the staff so that they can meet the needs of the residents. Views of the residents are sought so that they can contribute to the development of the service. Financial procedures are robust and safeguard the resident’s interests. EVIDENCE: The manager has undertaken and completed the Registered Managers Award. An annual quality audit is carried out and the information gathered is assessed at Head Office. An action plan is formed from the information for any improvement if required. Meetings are held for residents on a regular basis. Personal monies are held in the home for a number of residents. Records showed that all transactions have two signatures and receipts are kept for purchases. St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 15 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X 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 3 X 3 X X X St. Marys Nursing Home DS0000000207.V272854.R01.S.doc Version 5.1 Page 16 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. Standard Regulation Requirement Timescale for action 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 DS0000000207.V272854.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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