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Inspection on 06/09/05 for St Marys Nursing Home

Also see our care home review for St Marys Nursing Home for more information

This inspection was carried out on 6th September 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Care plans were comprehensive and gave details about the health and personal needs of the residents. A `day in the life` was completed which gave further information about the resident and their likes and dislikes. Many of the staff have worked at the home for a considerable length of time, work as a team and have welcomed staff that have moved to St Mary`s from another BUPA home.

What has improved since the last inspection?

Staff are appropriately supervised, which assists in promoting and safeguarding the best interests of the residents. The manager has continued to settle into her role and has maintained the stability within the staff team. Refurbishment and redecoration is ongoing throughout the home.

What the care home could do better:

There should be evidence to show that residents and/or relatives are involved in their individual care plans. A written alternative menu for residents should be available.

CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 1 The Crescent Linthorpe Middlesbrough TS5 6SD Lead Inspector Val Daly Unannounced 6 September 2005 09:30 am 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 B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 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 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 BUPA (Goldsborough) Ltd Mrs Jacqueline Elliott Care Home 50 Category(ies) of OP Old Age (50) registration, with number of places St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual who is under the age category can be admitted to the home on a permanent basis. 2. 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. Date of last inspection 30/09/04 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 fourty 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 B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 11.00 am and lasted for three hours. Three residents, staff and the manager were spoken to during the inspection. Numerous records including care plans, maintenance records and staff training records were examined. A tour of the premises was carried out. Residents spoken to said ‘the girls who look after us are very kind’. One resident said he could ‘come and go’ as he wanted as long as he let staff know. What the service does well: What has improved since the last inspection? 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 B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 6 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 B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 7 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) 1, 2, 3 & 6 A range of information is available, which enables residents to make an informed choice about where they would like to live. Each resident’s needs are assessed prior to their move to the home. The service does not provide intermediate care. EVIDENCE: The home has a Statement of Purpose, a Service User guide, a Brochure and information regarding finances. All of this information is available for prospective residents and their relatives. When an enquiry is made by telephone information is posted out to them. An assessment of need is carried out prior to the resident moving into the home to ensure that their needs can be met. Each resident has a written statement of terms and conditions. This home does not provide intermediate care. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 8 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 & 8 The health and personal care needs of resident’s are included in their care plans. EVIDENCE: Three care plans were examined and they each contained a detailed ‘day in the life of’ which gave a good picture of the resident and their likes and dislikes. Health, personal and social care needs were set out in individual plans of care, which had been evaluated regularly. There was evidence to show that General Practitioners, Consultants and District Nurses were meeting health care needs. In two of the care plans examined monthly assessments had last been completed in July 2005. Risk assessments were in place for the use of bed rails and they had been agreed and signed by a relative. However there was no evidence to show that relatives or residents had been consulted on and agreed to the care plans. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 9 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) 15 Menus do not include all the choices of food available. EVIDENCE: The menus showed that a variety of food was available for residents. There were choices for breakfast and tea, however there was not a written alternative menu for lunchtime. Whilst the manager was aware that residents were asked every morning about the lunchtime meal and the chef offered alternatives there needs to be a written alternative menu. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 10 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 & 18 The home has a robust complaints system in place. Staff have received training in adult protection issues which helps protect the residents. EVIDENCE: The home has a detailed complaints procedure and supporting records. One complaint had been made recently regarding items of clothing belonging to a resident and also the resident having dirty finger nails. The complaint was investigated and upheld by the manager. Training records showed that staff have received training in Adult Protection. The home has policies and procedures to follow to protect the residents in the case of suspected abuse. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 11 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 & 26 The home is generally safe and well maintained offering residents a homely environment in which to live. EVIDENCE: Maintenance certificates were in place and up to date. The water temperatures in baths and showers are taken and recorded every month. However the temperature in two showers had been recorded, as being 370 C and 390 C and one bath was 41.50 C, which is too cold. Staff also check the water temperature prior to a resident using a bath or shower. The water temperatures in the wash hand basins in resident’s bedrooms are in the maintenance plan to be checked six monthly, however the records showed that testing had last been carried out in February 2005. The home was clean and odour free. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 12 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) These four standards were not assessed at this inspection. EVIDENCE: St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 13 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) 36 & 38 Staff are appropriately supervised. Residents and staff are protected by the health and safety policies and procedures. EVIDENCE: The home has a formal supervision system for staff in place. There was evidence to show that supervisions were up to date. Health and Safety policies and procedures are in place and training for staff is carried out. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 14 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 15 No 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 7 Regulation 15 (1) Requirement Evidence must be available to show that residents and/or relatives have been consulted in the drawing up of care plans Water temperatures for baths and showers must be 43 degrees celcius or one degree either side. Timescale for action 30th October 2005 30th September 2005 2. 19 23 (2) 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 15 Good Practice Recommendations The menu should detail all food offered to residents. St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 16 Commission for Social Care Inspection Unit B - 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. Extracts may not be used or reproduced without the express permission of CSCI St Marys Nursing Home B51-B01 SN207 St Marys VN241052 060905 Stage 2.doc Version 1.40 Page 17 - 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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