Latest Inspection
This is the latest available inspection report for this service, carried out on 9th June 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Excellent.
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.
For extracts, read the latest CQC inspection for St Mary`s Nursing Home.
Annual service review
Name of Service: St Mary`s Nursing Home The quality rating for this care home is: The rating was made on: three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Pam Grace Date of this annual service review: 0 9 0 6 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service
Address of service: Margaret Street Stone Staffordshire ST15 8EJ 01785813894 01785819474 anne-clarke@tiscali.co.uk Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category physical disability Conditions of registration: English Dominican Congregation (Stone) Charitable Trust Number of places (if applicable): Under 65 Over 65 0 54 54 0 The maximum number of service users who can be accommodated is: 54 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability (PD) 54 Old age, not falling within any other category (OP) 54 Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service St Marys Home is a 57-bedded Care Home offering Nursing Care situated in Stone. It comprises of a three-storey purpose built building, built in early 1976. The current Proprietors The English Dominican Congregation has run the home since 1976. The home is set in a town location, however people using the service benefit from extensive views of large and beautiful gardens, which lead down to the fenced area
Annual Service Review Page 2 of 7 No alongside the canal. The home has 57 single bedrooms. Some bedrooms have ensuite WC facilities. Facilities/services include a hairdressing salon, laundry services, social activities, library and religious services. There is a summerhouse in the grounds and all areas of the home have access via stairs, ramps and passenger lifts. The visiting General Practitioners attend weekly or as required, and access is offered to the visiting dentist and chiropodist. The main emphasis of the home is to create a Christian environment, where every opportunity is given for the enhancement of the spiritual, physical and social well being of each individual. The Nursing staff and care staff encourage all of the people who live in the home to remain as independent as possible respecting individuality, autonomy and personal privacy. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information received and asked for, since the last key inspection on 10th June 2008. This included: 1 The Annual Quality Assurance Review (AQAA) completed by the Registered Manager, including a self assessment on how well outcomes have been met and numerical information about the service. 2 Any complaints we have and information we have about how the service has managed concerns, complaints and allegations. 3 Information received through notifications of things that have happened in the service in the past 12 months. 4 The previous Key Inspection report from 10th June 2008, and the results of any other visits we have made in the last 12 months. 5 Relevant information from other organisations. 6 What other people have told us about the service. What has this told us about the service? The Annual Quality Assurance Assessment AQAA was returned on time, and was well completed with evidence of how the service operates and has performed. We looked at the information in the AQAA, the history of the service, and the previous report. These evidenced that people who use the service are satisfied with the care, support, and services that they receive, and staff are being appropriately recruited, inducted and trained in their respective roles and responsibillities, in order to meet the needs of the people who use the service. The Annual Quality Assurance Assessment AQAA completed by the registered care manager told us about the following improvements they had made: A life biography has been included in the individual care plans, along with an activity profile. We now have more meetings with families to discuss their reatives care needs and review the care plan. We have updated our care plans to incoporate, a life history profile, an activity assessment, challenging behavior risk assessment, and a monthly assessment check list. More bedrooms have been extended to incorporate en suite facilities on all floors, new garden funiture has been purchased. We continue to purchase specialist equipment, and have purchased new wheelchairs recently. We have plans to redecorate the bathrooms on both floors. We will continue to extend and refurbish rooms as they become vacant. The holiday home in Llandudno has had a new central heating system installed, and Annual Service Review Page 4 of 7 the front porch has been completed, ready for the first group of residents to enjoy when they go for a five day holiday in June, with a second group booked in for July. We have developed a training needs analysis to ensure all staff have the correct training. Staff continue to undertake regular training, all the staff have recently completed an Abuse Awareness Certificate, and the majority of staff have taken a Certificate in Dementia Awareness. We have recruited more staff in the last twelve months who are NVQ trained and four more of our staff are at present enrolled on NVQ training courses, with plans in place for further staff to enrol once they have completed their course. One of the carers has completed the Certification in Provision of Activities in a Care Setting. Staff are all aware of the Mental Capacity Act and Deprivation of Liberty Safeguards. The Statement of Purpose and Service User Guide have been updated and a new Brochure is in the process of being produced. We have also gained more volunteers to assist with activities, including taking residents outside. As a result of a Health and Safety inspection we are now more aware of the danger of bed rails and have thus appointed two bed rail monitors. There had been no Safeguarding Adult Protection referrals made to Social Services. One complaint had been received by the Care Quality Commission CQC since the previous inspection. We visited the service on 23rd October 2008, and following our enquiries, we found that the complaint was not upheld. We were kept informed about important events, including incidents and accidents that have happened since the last inspection. The service is managed in a way that shows it has the interests of the people who use the service as the focus of activity. At the previous inspection, the standard of service was judged to be excellent 3 star. There were two recommendations and no requirements made. It was recommended that the documentation in care plans be further developed in order to ensure that instructions in plans are clear and consistent for staff to follow. It was also recommended that a member of the kitchen staff be employed for the evening to ensure that care staff do not have to carry out kitchen duties but are able to remain on the floor to meet the care needs of the residents. Following our random visit in October, to make enquiries about a complaint, we made four recommendations in regard to the development, monitoring and reviewing of care plans, and the involvement of people and or their representatives in the care planning process. All of these recommendations will be monitored at the next inspection. Our judgement is that the agency is still providing an excellent service, and they know what further improvements they want to make. What are we going to do as a result of this annual service review? Annual Service Review Page 5 of 7 We believe that the quality of this service has been maintained since the previous inspection. We plan to do a Key Inspection by June 2011 to review our assessment of the agency. However, we can inspect the service at any time if we have concerns about the quality of the service, or the safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
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