Care Home: St Mary`s Court

What has improved since the last inspection? St Mary`s CourtDS0000073035.V375216.R01.S.doc Version 5.2 Page 7Not applicable on this occasion as this is the home`s first inspection since it`s new registration with new providers on the 19th November 2008, and this key unannounced inspection was to take place within six months of that registration. What the care home could do better: An audit system to check the signing, omissions of medication and transcribing of medication on medication administration (MARS) sheets must be in place so that other possible medication issues can be monitored and good practice is always adhered to. Signatures and dates on pre admission assessments and correlation of care plans in daily recordings requires attention to ensure a concise audit trail is in place. Dates times and signatures on documentation must be given more prominence, so an audit trail is in place for the home and correlation between the care plan and daily evaluations must be evident and the care plan therefore being a working document. CRB checks that highlight issues requiring discussion should have clear records maintained to evidence this has happened. The home must ensure regular fire drills are undertaken by all staff and record the date, time and names of all staff attending. Key inspection report CARE HOMES FOR OLDER PEOPLE St Mary`s Court The Old Deanery Care Village Deanery Hill Bocking Braintree Essex CM7 5SR Lead Inspector Helen Laker Unannounced Inspection 6th May 2009 10:00 DS0000073035.V375216.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Court Address The Old Deanery Care Village Deanery Hill Bocking Braintree Essex CM7 5SR 01376 328600 01376 344278 bernard@olddeanery.com 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) Anglia Retirement Homes Limited Bernard Mawoyo Care Home 90 Category(ies) of Dementia (90), Old age, not falling within any registration, with number other category (90) of places St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing only - Code N to service users of the following gender: Either whose primary needs on admission to the home are within the following categories: Dementia - Code DE Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 90 Not Applicable 2. Date of last inspection Brief Description of the Service: St Mary’s Court is a purpose built new home set in ten acres of beautifully landscaped gardens with pathways surrounding the home. The home comprises of three separate units on three floors named Cedar (First Floor), Beech (Ground Floor) and Ash (Lower Ground Floor) with a total of 88 single rooms and one companion room on the lower ground floor (Ash unit) all with en suite facilities. St Mary’s Court is registered for 90 beds in total 37 of which are nursing. The home admits both residents with dementia and the frail elderly requiring specialist nursing care. Ash on the lower ground floor and Beech on the ground floor specialise in dementia residential care. Cedar which is on the top floor, caters for frail elderly residents requiring nursing care. The home is set in large well maintained gardens with an enclosed courtyard provided. Car parking is available and security gates are provided at the entrance to the home. St Mary’s Court is situated on the same site as The Old Deanery, in the village of Bocking, which is within easy reach of the town of Braintree and surrounding facilities. There is also furnished accommodation, for independent living, in a two bed roomed flat on the third floor in The Old Deanery. Clear criteria are set with regard the tenancy and a separate contract states that tenants access to the home and grounds is limited to flat access only, unless invited to visit. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 5 A copy of the most recent inspection report issued by the Care Quality Commission will be made available in the entrance hall of the home. The fees charged for care and accommodation at St Mary’s Court range from £453.11 to £950.00 per week, this information was provided by the registered manager on 05/05/09. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key unannounced inspection was carried out as part of the annual inspection programme for this home and looked at all the key standards for care of older people. It took place on a weekday between 10.00 and 16.00. The staff and manager were present throughout most of the day and the proprietor and operations director also attended during the day and assisted with the inspection process by supplying documents and information. A tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to the CQC. The AQAA provides an opportunity for the service to tell us what they do well and areas they are looking to improve and/or develop. It is anticipated that any improvements or changes be noted as this contributes to the inspection process and indicates the home’s understanding of current requirements, legislation changes and own audited compliance. Ten residents, three relatives and five staff were spoken with during the inspection. Feedback survey sheet were sent out by the CQC and comments from these have been taken into account when compiling the report. What the service does well: The information available to people making St Mary’s Court their place of residence, is very informative. The individuals spoken with were proud of their home and the way of life it provided them with. The people living at St Mary’s Court appreciated the choices of how they spent their day and the opportunities for activity and stimulation. The home was clean, fresh and maintained to a very high standard. The home can provide a good overall standard of care to residents with dementia. Residents seen were happy living at the home and interact well with staff and observation and discussions with residents’ indicated they were relaxed and comfortable. What has improved since the last inspection? St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 7 Not applicable on this occasion as this is the home’s first inspection since it’s new registration with new providers on the 19th November 2008, and this key unannounced inspection was to take place within six months of that registration. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 8 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 Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & Standard 6 does not apply to this service Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that their identified needs can be met. Information available to prospective residents is comprehensive and ensures they can make an informed decision about living at the home. EVIDENCE: St Mary’s Court provides a comprehensive package of information for people considering moving into the home. An up to date statement of purpose and service users guide is available and the home has a website containing plenty of information and photographs to provide an overview of life at the home and the facilities available. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 10 The manager assesses prospective residents before they come to live in the home, and a record of a pre-admission assessment showed that appropriate issues were considered. Discussions with the people living at the home during this visit confirmed they felt they had received enough information about the home to enable them to decide if it was the right place. Significant time and effort is made making the process of admission into the home personal and well managed. There is a checklist to follow and the home uses a recognised scoring system called quest to ascertain admission criteria. Attention was required to dates and times to ensure an accurate audit trail was present. Training is provided to help staff develop the necessary skills to support new residents through the process of moving into the home and settling in. The AQAA states “All enquiries receive a full brochure and information about the home. All relatives and if possible prospective residents are encouraged to visit the home. A full comprehensive detailed pre-admission assessment is carried out by the manager or deputy manager, this information is then used to formulate person cantered care plans when residents are admitted.” All service users consulted felt that they received the care and support they needed, and relatives who provided feedback all felt that the home meets the needs of individuals and gives them the support the relative expected. All individuals spoken with felt that whatever the circumstances of their admission to the home, it had been a positive move. One family member said, “We came and looked at the home and it had everything we wanted it was the best choice for our relative.” The home does not provide intermediate care. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples needs are assessed in a person centred way that enables staff to have a better understanding of each individual. Residents are assured that the care and support they require to meet their needs is planned and recorded sufficiently well to guide staff in promoting their well being and safety EVIDENCE: The care plans relating to five of the people living at St Mary’s Court were examined at this visit to assess how the service understands the way in which it should plan and meet their needs. The care plans contain a variety of assessments that identified the level of support the individuals require in their daily lives. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 12 These included activities of daily living, equality and diversity, dementia care mapping tools and deprivation of liberty checklists. Plans are regularly reviewed and updated to show changes, with clear review notes maintained. Evidence of individuals’ involvement with developing their own plan of care is available through monthly quality assurance questionnaires and within the care plans. The health care of people living at the home is monitored through the documents contained in care plans; these also include health professional visits and their outcomes, monitoring sheets for weight and dietary intake etc. The AQAA states “We formulate person centred care plans and the health and personal care is geared to the resident’s routine.” All people providing feedback confirmed they receive the medical support they need, with one saying “I always get to appointments when I need them and have no problems with my medication not being given”, and one relative confirmed the same saying “The attention paid to medical care is second to none.” Aids and equipment are provided to encourage and promote independence for people living at the home and the risk management framework supports individuals to maximise their independence. The service arranges training on healthcare and topics that are relevant to the people they support. An example of this was outlined in the home’s AQAA and states” As St Mary’s is a new home the manager has identified the importance training staff on how to cope with a dying resident and the importance of support to the resident and family. Training is being arranged through the coop funeral services for staff.” The registered manager was able to report that the home receives good support and enjoys excellent relationships with varied healthcare professionals that are involved with the home such as the falls co-ordinator and community pharmacist. Medication is administered from trolleys that are stored securely when not in use. The daily administration of medication is generally well recorded however some gaps were evident. Medication Administration Records (MAR) sheets were neat but there were some missing signatures and too many hand written prescriptions without two signatures being evident. A signature audit may be of value to keep this issue in check. Staff need to make better use of the omissions code located on the bottom of the MARS sheet. Items are checked in to the home and returns systems are in place. No residents are presently selfadministering. Controlled medications were in order and there was evidence of medication being kept under review. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 13 People living at St Mary’s Court made many positive comments about the staffs’ attitude towards them. They felt that their dignity and privacy were respected. Good practice was observed during this site visit for example, staff were seen to knock on doors before entering a room and ensured that doors were closed when attending to residents’ personal care needs and sensitive assistance was provided at mealtimes. Comments received from the people at the home included “They help me very well and they are lovely staff” and “The staff are wonderful, I don’t know what I would do without them” Additionally a relative stated, “We have no problems with the care it is very good and they are treated with respect.” St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at St Mary’s Court are able to make choices about their lifestyles and the social, cultural and recreational activities meet their expectations. Residents continued contact with family and friends is welcomed and encouraged by the home and they are provided with a wholesome, tasty and balanced diet. EVIDENCE: Central to the ethos of the home is the promotion of peoples’ rights to live fulfilling lifestyles. People living at the home are encouraged to enjoy a stimulating life with a variety of leisure activities and opportunities to choose from. Examples of these include: Snoezelen visits, Garden and bistro visits, keep fit, film afternoons, cooking, hand and nail care and ball games and skittles. The AQAA states “At present our service provides a range of cognitive stimulation methods including reminiscence, arts and crafts, movement and dance, fun and games, massage therapy, gardening etc. This approach St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 15 appears to work as a person-centered approach is utilized.” On the day of this visit a group of people were enjoying a game of skittles with an activities coordinator and another was noted to be enjoying hand and nail care. Television is available in all bedrooms. The service employs two activities co ordinators currently, dedicated to providing entertainment and leisure activities, and plan to have one on each floor when fully occupied. The AQAA additionally states “There is potential for improvement mainly for clients who are severely affected with dementia. The activity organizer and other staff members will be sent for training sessions that will help to develop staff.” NVQ training is being addressed for these staff also. The manager has identified that over the next twelve months the home intends “To ensure we effectively provide cognitive stimulation activities for our service users who are severely affected with Dementia, St Mary’s will work in partnership with the local Older Peoples Community Mental Health Team, mainly the Psychologist and Occupational Therapist (OT) to help identify effective cognitive stimulation approaches. St Mary’s will aim to facilitate joint cognitive stimulation activities with the Psychologist and /or OT. Learned approaches will be taught to all staff in the home.” Visitors spoken with during the course of this visit were very positive about the care and support provided for their friends and relatives living at the home. The people living at the home were also happy to talk with us about their experiences of living at St Mary’s Court. Everyone consulted confirmed that their lives were arranged around their personal wishes such as what times they went to bed or arose, when they bathed/showered and what they chose to do with their time during the day. One person consulted stated, “I am very comfortable here” and evidence was available to demonstrate where family members had been involved in decisions regarding arrangement of personal possessions in their relative’s bedroom. One family member said when consulted: “A choice is always offered and it is nice that we don’t have to worry” Lockable memory boxes are located outside all rooms which can be filled with photos and personal memory items and these were seen to be well displayed for all those service users in residence. The home has dining areas with satellite kitchens on all floors, these rooms were large enough and meals could be served in service users rooms if they so wished. The main kitchen is located at the home’s sister home the Old Deanery located in the same grounds. The manner in which the meal was served was dignified and respectful, the atmosphere was sociable and pleasant. Staff were noted to assist people that were less able to eat respectfully and in a timely fashion. The people living at the home were complementary with regard to the meals at the home. The menu is displayed outside both dining rooms and offers a good choice of healthy meals. A night time menu has also been developed for those who require snacks or drinks out of meal time hours. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 16 The cook prepares several choices each day that are nutritional and healthy. Family members and service users stated “The food is really good” and “They can have what they want at anytime crisps, drinks and biscuits etc”. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can feel confident they can express their concerns with the confidence that they will be listened to and taken seriously Residents can also be assured that all carers are appropriately trained to safeguard their welfare. EVIDENCE: The service has a complaints procedure that contains appropriate information to ensure the people living at St Mary’s Court or other interested parties know what to do if they need to make a complaint, including timescales for response and contact details for the Care Quality Commission (CQC). All the residents consulted as part of this visit said that they knew who to speak to if they were not happy, and knew how to make a complaint. Those spoken to were confident to speak up if they had any concerns, and felt that any concerns would be listened to and acted on. Relatives spoken with all knew how to make a complaint, and were happy that the service responded appropriately to any issues raised. The AQAA states “We have a clearly defined company complaints policy with agreed timescales for managing complaints. The home has robust policies for dealing with allegations of abuse or neglect. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 18 All staff have POVA training during their induction and are taken through the channels of reporting abuse. The home’s manager has also attended the course”. Staff spoken with showed a good awareness of whistle blowing and adult protection procedures. The ethos of the home is to welcome comments and complaints and the manager of the home actively promotes this. All staff are encouraged to promote this and to not be defensive when residents or their relatives complain. Since the AQAA was submitted the CQC has received one complaint and one safeguarding referral was made by the home. Both were responded to appropriately and are resolved. The complaint was only partially upheld and the safeguarding referral was not progressed due to lack of evidence. Records provided evidence that staff members had attended required training in the Protection of Vulnerable Adults. The AQAA informs us that the home’s plans for the next twelve months include “To encourage residents/relatives to provide us with feed back(good or bad) and avoid getting any complaints and provide on going abuse and refresher abuse training.” The home has also received compliments that contained varied items of positive feedback from families, even though the home is not at full capacity yet. The service has a policy and procedure for dealing with the Protection of Vulnerable Adults and the manager and staff are aware of the need for training and vigilance with regard to adult protection. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can be sure the home provides a safe, well-maintained environment that is accessible to them that is well maintained, homely and meets their individualised needs . EVIDENCE: The home is very well maintained and attractive with a variety of communal internal and external space available for residents to use. The AQAA tells us “The home has been specially designed ensuring that the environment specially caters for residents suffering from Dementia. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 20 Some areas include the use of good colour contrasts. Offering variety areas to sit and a snoezelen room.” A tour of the home confirmed there is a selection of communal areas both inside and outside the home so that people living at the home have a choice of places to sit quietly or meet with family and friends. The bedrooms are mainly single with the exception of one shared room and all are en suite (with one companion room) and provide adequate space for the recommended furnishings including armchairs. The rooms were pleasantly laid out with low windows to enable residents to see out when seated, and had been personalised with resident’s choice of décor and belongings. The bathrooms were easily accessible to all people living at the home and were decorated to a good standard, pleasantly tiled and well equipped. The Manager also states in the AQAA that “Continual audits to identify areas that require refurbishment when the need arises.” They plan to “Continue to improve the dementia care environment by also looking at getting exotic birds, which have been proven to be therapeutic.” The home employs a maintenance person who keeps the home and gardens safe and in good repair. Grounds were well maintained. Maintenance and decoration records were not viewed on this occasion, however it was evident from a physical tour of the building that the service is very proactive in this area. On the day of inspection external garden areas were still being developed and were all well appointed and safe. The kitchens and shared laundry were very clean, organised and efficient. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service can expect that there will be sufficient staff available to meet their needs. They can expect to be supported by staff that have the knowledge and skills required to meet their needs. Recruitment practices meet regulatory requirements set out to protect residents. EVIDENCE: The home maintains staffing levels appropriate to the needs and number of people living there. Individuals consulted felt that there are always sufficient staff available when they need them, and relatives consulted felt that staff have the right skills and experience to look after residents properly. Throughout the inspection visit the atmosphere was calm and peaceful. People consulted with also commented that they did not feel rushed at any time of the day, they were given time to get up and did not feel that staff were overly stretched. The staff interacted with residents in a respectful and pleasant manner. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 22 People living at the home and their relatives gave very positive feedback about the calibre of staff employed to work at the home. One resident stated “Staff are helpful and very caring and courteous” and another commented “They know what they are doing and that is what matters”. Discussion with the registered manager and scrutiny of records confirmed that the service is proactive in its staffing, recruitment and training, with planning for the potential needs of people who may use the service in the future. Staff files were examined to determine how the service carried out its recruitment process. The documents on the files seen demonstrated a robust approach with checks made on the persons Criminal Records Bureau (CRB) check, and the Department of Health Safeguarding POVA first list, as well as two written references, and proof of the persons identity. These with the completed application form assist the service to determine whether the person is of a suitable background to work with vulnerable people. One CRB check which had warranted some discussion did not have any supporting documentation to evidence this and this was discussed with the manager on the day of inspection and the importance of recording discussions of the same. Staff are provided with relevant training that is targeted on improving outcomes for people living at the home. The registered manager maintains a list to ensure that all staff training/refresher training is delivered promptly. The staff training programme demonstrated that staff undertook a variety of courses pertinent to their work including skin care, medication, dementia and dementia care mapping, Safeguarding, falls prevention, infection control, fire safety, food hygiene, first aid, moving and handling and POVA. Training needs analysis forms are completed so staff can identify their own training needs. Evidence was available to confirm that staff meetings and staff supervision take place regularly. Heads of department meetings take place regularly where training, activities, new staff and policies and procedures are some of the things discussed, the outcomes of these meetings are cascaded through individual departments/floors to ensure good communication throughout the service. The AQAA identifies that the home hopes to progress over the next twelve months by “Continued recruitment and retention of excellent staff. The implementation of the yearly training plan incorporating mandatory training and other specialist subjects, such as dementia care, catheter care, nutrition, safeguarding adults, end of life care etc will help staff to continually update their knowledge and skills base. Multi disciplinary working will also enable a good knowledge and skill base for our staff team. Continued professional development will be a priority for all staff at St Mary’s as this will facilitate a greater level of understanding and promote good practice by staff. The home has established good links with the Alzheimer’s Society and will be implementing good practices advised by the Alzheimer’s Society.” St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Mary’s Court is well run by a competent management team and people living there can be confident that the home is run in their best interests. There are health and safety systems in place to ensure the welfare of both individuals and staff. EVIDENCE: The manager is able to demonstrate an awareness of good management practices and also an enthusiasm and commitment to raising and maintaining high standards in the home. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 24 The manager is experienced, a qualified registered nurse and has completed the Registered Manager’s Award. The manager demonstrates an active commitment to developing the home. Through discussion with the registered manager it is clear there is good awareness of current Care Quality Commission, social care inspection guidance such as the Key Lines Of Regulatory Assessment (KLORA) and good knowledge of the National Minimum Standards. The service operates a constant system of monitoring ‘customer’ satisfaction including ongoing audits. Responses indicated a high level of satisfaction of the care and services provided at the home. People spoken with feel the manager is very approachable and runs the home well. One person said, “the manager and staff very kind and helpful”. The service does not directly maintain cash balances for people living at the home. It was reported that where individuals who did not look after their own monies and wished to purchase items or have their hair done, or participate in outings the service supported this and a monthly invoice was sent to family/representative providing a breakdown of where monies had been spent. Health and safety policies and procedures were not specifically inspected on this occasion, as the home is a new build and at the time of this inspection had only been operational for five months. The home appeared very wellmaintained and safe, and information submitted to the CQC indicated routine servicing and checks would be kept up-to-date. Fire drills were noted to need organising more regularly and the date, time and names of all staff attending (including night staff), to be documented to ensure all staff benefit from the training. The AQAA states “We are constantly reviewing our practices which will enable us to continually improve and run in the best interests of the residents using our service. Using evidence-based practice to back up our daily routines will contribute to the service we provide. The home will continue to maintain good links with the multidisciplinary teams in asking for specialist advice, support and partnership working. Providing person centred care by involving residents and relatives when formulating and reviewing care plans will encourage staff to provide individualized care. Suggestions and views of service users and significant others will be taken on board to facilitate an improved service. Quality audits carried out 72 hours after admission and regularly thereafter will also help to improve the quality of care provided. Continued professional development for all staff will also enable our service to continually improve.” St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 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 3 X 3 X 3 X 2 3 St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation Reg 13 Requirement An audit system to check the signing, omissions of medication and transcribing of medication on MARS sheets must be in place so that other possible medication issues can be monitored and good practice is always adhered to. Timescale for action 30/08/09 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 3 Refer to Standard OP28 OP37 OP37 Good Practice Recommendations CRB checks that highlight issues requiring discussion should have clear records maintained to evidence the same. Dates times and signatures on documentation must be given more prominence on all documentation, so an audit trail is in place for the home The home must ensure regular fire drills are undertaken by all staff and record the date, time and names of all staff attending. St Mary`s Court DS0000073035.V375216.R01.S.doc Version 5.2 Page 27 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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