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Inspection on 08/09/05 for St Michaels Nursing Home

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

This inspection was carried out on 8th 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

The home provides a friendly, comfortable and homely environment where consistent team working is promoted. There are well-established management systems in place, which promote the health, safety and wellbeing of service users, staff and visitors to the home.

What has improved since the last inspection?

The eight requirements detailed in the previous inspection report had been achieved. There is a comprehensive programme in place for the proposed repair, renewal and upgrade of the fabric of the building, which details timescales for achievement of items programmed.

What the care home could do better:

The registered person should ensure that they take responsibility for the conducting of monthly visits to the home and the provision of monthly reports in respect of those visits, to the Manager (when in post) and the Commission in accordance with Regulation 26 of the Care Homes Regulations.The registered person should ensure that the programme for the redecoration and renewal to the fabric of the building is fully completed, as there are areas of the building which look `tired` and in need of upgrading. The maintenance status of the hot and cold water systems requires clarification.

CARE HOMES FOR OLDER PEOPLE St Michaels Nursing Home 9 Chesterfield Road Brimington Chesterfield Derbyshire, S43 1AB Lead Inspector Susan Richards Unannounced Inspection on 08 September 2005 at 10:00 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 Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Michaels Nursing Home Address 9 Chesterfield Road, Brimington, Chesterfield, Derbyshire, S43 1AB 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) 01246 558828 01246 233768 Sun Care Homes Ltd vacant Care Home 39 Category(ies) of Older persons, not falling within any other registration, with number category (39) personal and nursing care of places St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. One PD place for the person named in the notice of proposal letter. Date of last inspection 05th March 2005 Brief Description of the Service: St Michaels Care Home provides accommodation, nursing and personal care and support for up to 39 older persons. It is located approximately 2.5 miles north east of Chesterfield town centre on a direct bus route and within a residential area. The home provides a choice of loungedining space and individual accommodation comprises of 29 single bedrooms and 10 shared (two of which are currently used for single occupancy). Fifteen of the single bedrooms have an en suite. There is a pleasant enclosed rear patio and wellkepot garden area providing a choice of seating, which is accessed via a conservatory. There is a choice of bathroom and toilet facilities to each floor. A passenger lift is provided and there is an emergency call system throughout the home. A variety of disability equipment is provided, both environmental and individual equipment. Care is assessed, planned and reviewed by Registered Nurses employed in the home, who are supported by a team of care and hotel services staff. The Registered Managers post is vacant. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was on the physical environment and the arrangements for the staffing, management and conduct of the home. The views of some staff and service users/representatives were considered in relation to these. What the service does well: What has improved since the last inspection? What they could do better: The registered person should ensure that they take responsibility for the conducting of monthly visits to the home and the provision of monthly reports in respect of those visits, to the Manager (when in post) and the Commission in accordance with Regulation 26 of the Care Homes Regulations. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 6 The registered person should ensure that the programme for the redecoration and renewal to the fabric of the building is fully completed, as there are areas of the building which look ‘tired’ and in need of upgrading. The maintenance status of the hot and cold water systems requires clarification. 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 Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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 Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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) The standards in this section were not assessed on this occasion. EVIDENCE: St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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) The standards in this section were not assessed on this occasion. EVIDENCE: St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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 standard(s) The standards in this section were not assessed on this occasion. EVIDENCE: St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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 standard(s) 16 & 18. There were satisfactory systems and arrangements in place to enable service users and/or their representatives to complain or raise their concerns and to ensure that service users are protected from abuse. EVIDENCE: The complaints procedure for the home was openly displayed and additional written information was provided for service users and their representatives by way of the service user guide and in the quiet/visitors room. Staff spoken with was conversant with the home’s policies and procedures and their responsibilities in relation to complaints made. A record of complaints received is kept, together with details of action take and outcomes. There had been no complaints made since the previous inspection. Recognised procedures and policy guidance was in place in relation to the protection of vulnerable adults, management and handling of service users monies and dealing with violence and aggression. Staff spoken with was familiar with these and training and updates were provided for staff in respect of abuse awareness and adult protection. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 12 St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 13 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, 20, 21, 22, 23, 24, 25 & 26. Overall service users live in a safe and reasonably well-maintained environment, which generally provides adequate facilities and equipment. However, the completion of the programme of upgrading, repair and renewal to the home is essential as is the confirmation of the safety of the hot and cold water systems and the provision of a working mechanical sluicing disinfector. EVIDENCE: The Inspector conducted a tour of the premises and inspected all communal and service areas and a number of service users own rooms. All parts of the home seen were clean and free from hazards, with the exception of the lack of a functioning mechanical sluicing disinfector and the need for clarification as to the maintenance and status of the hot and cold water systems. A written programme for the upgrade, repair and renewal of the fabric of the building has been provided since the previous inspection. This was examined and discussed. Progress was identified as being behind schedule due major expenditure and works on the total replacement of the fire alarm system, St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 14 which had been completed, although not included in the original planned programme. Key areas, which require attention, were discussed with the Acting Manager and also the outcome of the Fire Officer’s most recent visit, which was deemed satisfactory by him. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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 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, 28, 29 & 30 There were satisfactory arrangements in place for the proper recruitment, induction, training and supervision of staff and to ensure that service users’ care needs were being met by the numbers and skill mix of staff. EVIDENCE: The arrangements for the staffing of the home and also for the recruitment, induction, training and supervision of staff were discussed with the acting manager and some staff on duty at the time of the inspection. Policies and procedures were also inspected in relation to these. Records were also examined in respect of the above, together with related records, such as accidents/incidents and complaints. Although previous rotas indicated that there had been some staffing difficulties, current rotas and discussions with staff and service users indicated that these had been resolved and that staffing arrangements were satisfactory. There were well-established arrangements in place in relation to staff training and staff spoken with felt that access to training was good, including that relating to the arrangements and provision for care staff to access NVQ training. Seventy five percent of staff had achieved at least NVQ level 2, with further undertaking this. Records of staff training undertaken were kept. The Manager advised of training proposed in the future, however there was no actual recorded training plan in place. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 16 St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 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, 32, 33, 34, 36, 37 & 38. There were generally well -established and satisfactory management systems in place to promote the health, safety and welfare of service users, although the maintenance status of the hot and cold water systems was not confirmed. The acting manager was carrying out and providing monthly written reports as to the conduct of the home and the care provided therein, which is contrary to the requirements of Regulations 26 of the Care Homes Regulations 2001, which clearly identifies this as the responsibility of the responsible individual or those persons specified. The registered person/responsible individual has not formerly notified the Commission of the intended management arrangements following the departure of the current acting manager, in the absence of a registered manager. EVIDENCE: St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 18 The registered manager, who had successfully managed the home for many years, had terminated her employment since the previous inspection. The acting manager had also given written notice to terminate her employment and openly announced her departure. There was no recorded annual development plan for the home. There was a system in place in respect of clinical benchmarking and for the auditing of some aspects of the home’s care and service provision. The Inspector also discussed the arrangements for the review of service user’s satisfaction with the care and services provided in the home. Details of established methods used by the home to ascertain this were provided, including periodic satisfaction surveys. The arrangements for the supervision of staff were also examined – comments made under the staffing section of this report in relation to these are also applicable here. A number of records which are required to be kept by the home were examined during the inspection process, including: Staff records Admission records Regulation 26 (monthly visit by provider) reports Staff duty rotas Complaints record Accident and incident records Fire records Visitors record These were generally satisfactory and in accordance with requirements, except the regulation 26 (monthly visit by provider) reports. These were being undertaken and recorded by the acting manager and not the registered provider as is required. The arrangements for staff core health and safety training, which included moving and handling, fire, first aid and food hygiene and handling were examined (including records, policies and procedures) and discussed with the manager and staff and were satisfactory. The arrangements for the maintenance of equipment in the home were examined and were generally satisfactory, although there was no up to date maintenance certification in place for that relating to hot and cold water systems. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 19 St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 20 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 N/A N/A 3 3 x 3 2 2 St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 21 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 OP19 Regulation Requirement Timescale for action 31.03.06 2. 3. OP25 OP25 4. OP25 5. OP31 6. OP37 23(2)(b)(c The written programme for the )(d)(k)(n) upgrading, repair and renewal of the building must be fully completed. 23(2)(c & The mechanical sluicing (k) disinfector must be repaired or replaced. 13(4)(c The status of the maintance of the hot and cold water systems must be confirmed by suitable certification. 13(4)(c Records of hot water temperatures must clearly indicate baths and showers tested and ensure that hot water emitted from these outlets provides water close to 43 degrees centigrade (between 4143 acceptable). 38(1) & The registered provider must (2) notify the Commission of the arrangements for the running of the care home in the absence of a registered manager and acting manager. 26(2)(3)( On a monthly basis, the 4) & (5) responsible individual must conduct their visits to the home in accordance with the requirements of the said regulation and provide a written C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc 08.11.05 08.11.05 08.10.05 08.10.05 08.11.05 St Michaels Nursing Home Version 1.40 Page 22 report under the requirements of (4)(c to the Commission and the registered manager of the home and any of its directors/partners. 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 OP33 Good Practice Recommendations There should be a recorded annual development plan provided for the home. St Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 23 Commission for Social Care Inspection South Point 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 Michaels Nursing Home C52 C02 S59738 St Michaels V248693 080905 Stage 0.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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