Care Home: St Marys Nursing Home

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What has improved since the last inspection? The statement of purpose and service user guide should be reviewed to ensure that all information is current. The improvement in the medications systems was particularly pleasing as two of the three requirements made following the last inspection were associated with medication. The requirements made at the last inspection had resulted in the head of care and the quality manager carrying out weekly medication audits and identifying any problems and putting in the appropriate training.St Marys Nursing HomeDS0000017693.V375227.R01.S.docVersion 5.2Page 7 What the care home could do better: Some requirements and recommendations were made as a result of this inspection but in out judgement the outcomes for the people using the home were good. We believed that for some people the large portions they were given at mealtimes made them reluctant to eat. Some areas of the home, particularly communal areas were in need of redecoration. Staff must take care to record accurately so that the correct care is provided. Key inspection report CARE HOMES FOR OLDER PEOPLE St Marys Nursing Home 19 Dunstable Road Luton Bedfordshire LU1 1BE Lead Inspector Sally Snelson Unannounced Inspection 30th April 2009 08:45 DS0000017693.V375227.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 Marys Nursing Home DS0000017693.V375227.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 Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marys Nursing Home Address 19 Dunstable Road Luton Bedfordshire LU1 1BE 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) 01582 438200 01582 484116 winfielo@bupa.com www.bupa.co.uk BUPA Care Homes (ANS) Ltd Manager post vacant Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users admitted prior to 01/06/05 may have a diagnosis of dementia. Up to 10 service users can be admitted under the age of 65. Date of last inspection 6th May 2008 Brief Description of the Service: St Mary’s Care Home is a purpose built nursing home situated in central Luton on the site of an old hospital. The home provides single bedroom accommodation for service users over the age of 65years. The original building has been extended to provide 60 bedrooms on two floors accessed by a shaft lift. There is an open courtyard area with seating where in the summer plants provide interest and colour. The bedrooms are varied; some in the older part of the building have retained their original features. A number of communal rooms provide service users with a choice of seating areas. There is adequate staff and visitor car parking space. Staff are divided into two teams to deliver care, each team covering one floor. The staff teams are made up of qualified nurses, carers and senior carers supported by teams of housekeeping and administrative staff. At the time of the inspection the home had 18 beds dedicated to providing rehabilitation to people on behalf of health. This area was staffed by the homes staff, but had a number of community staff, including physiotherapist and occupational therapists, visiting and assessing the service users throughout their stay. Fees for this service start at £566.30 per week for those funded by social services, and private rates are £850.00 per week. These rates then vary depending on the individual needs required and include the nursing fee. Additional charges are made for hairdressing, chiropody, telephone calls and newspapers. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for older people, that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Sally Snelson undertook this inspection of St Mary’s. It was a key inspection, was unannounced, and took place from 08.45am on 30th April 2009. Alan Bristow, the acting manager, was present for the whole of the inspection. Feedback was given throughout the inspection to the relevant staff, and at the end to the acting manager, the new manager who was due to take up post on the 11th May 2009, and the quality manager who was visiting the home that day. During the inspection the care of four people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, visitors, and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. In addition to long term nursing care the home also admitted people for intermediate care and rehabilitation. This area was staffed by the homes staff, but had a number of community staff, including physiotherapist and occupational therapists, visiting and assessing the service users throughout their stay. The inspector would like to thank all those involved in the inspection for their input and support. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 6 What the service does well: The home was clean and tidy and residents had their own rooms with en-suite facilities. The activity co-ordinator told us that the resident had been using the garden when the weather was suitable. Admissions to the home only took place once the service was confident that staff had the skills, ability and qualifications to meet the assessed needs of the prospective resident. Medication procedures were adhered to and the medication records were fully completed and provided a robust audit trail. Resident’s were treated with respect and dignity and offered choices at all times and had the opportunity to maintain important personal and family relationships. Visitors were welcomed in to the home at anytime. A robust complaints procedure and staff awareness of safeguarding ensured people were kept safe at all times. The home had processes in place to continually audit and monitor the care provided so that any problems could be rectified quickly. A variety of training was offered to all of the staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. What has improved since the last inspection? The statement of purpose and service user guide should be reviewed to ensure that all information is current. The improvement in the medications systems was particularly pleasing as two of the three requirements made following the last inspection were associated with medication. The requirements made at the last inspection had resulted in the head of care and the quality manager carrying out weekly medication audits and identifying any problems and putting in the appropriate training. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 7 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 Marys Nursing Home DS0000017693.V375227.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 Marys Nursing Home DS0000017693.V375227.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): 1,2,3,4,6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions to the home only took place once the service was confident that staff had the skills, ability and qualifications to meet the assessed needs of the prospective resident. EVIDENCE: We saw a copy of the Statement of Purpose and the Service Users Guide. These included all the required information and had been updated with the latest managerial changes. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 10 Those residents who had been admitted for long term care had appropriate contracts that detailed what they could expect from St Mary’s, the cost, and how the fee was to be paid. Prior to their admission the acting manager assessed all prospective residents. The residents who came to St Mary’s for rehabilitation were first assessed by the Primary Care Trust (PCT), who were funding their places and responsible for much of the care package. The acting manager would then carry out an assessment to ensure that the staff team were not put into the position of having to provide care to residents that they did not have the relevant training and experience to care for. Training files (see staff section of this report) confirmed that collectively the staff team had the necessary skills and qualifications to care for the people living at St Mary’s. One person we spoke to said “I knew about this place, but not that it was like this and could help me” The home had dedicated one area for rehabilitation and the health staff worked from this area. However there were no restrictions on residents moving around the home and using other areas if they wished. All prospective residents were offered the opportunity to visit the home before moving in. St Marys Nursing Home DS0000017693.V375227.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): 7,8,9,10,11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Medication procedures were adhered to and the medication records were fully completed and provided a robust audit trail. Regular management checks monitored compliance. EVIDENCE: The four care files we looked at had care plans that been written for all of activities of daily living. They were written in sufficient detail to ensure that staff had enough information about how to provide care. There was evidence that some of the people using the service had been consulted about their plans. The care plans had been reviewed monthly and were updated as needs St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 12 changed. However we were disappointed to read some small mistakes that had not been picked up and altered by the staff that should have been using the plans daily. For example, we saw the following written statement:- make sure (name of resident) is wearing a clean dress. This resident was a gentleman. The acting manager told us that BUPA provided a bank of suggested comments for staff to use in care plans and this may have been the reason for this incorrect statement being written. We also saw in another file a review that stated:- (name of resident) has shower once or twice a week. The resident told us that she had refused all showers except one and preferred a strip wash. Staff agreed that the review of the care plan should have read, offered shower once or twice a week. Again all the staff providing the care should have been reading this and once the mistake was identified the necessary alterations should have been made. Also we noted that it had been identified that a person who had had a significant weight loss had had appropriate medical advice, but had not been weighed weekly as the assessment tool identified. However when this person was weighted a month later the weight increase had also been significant, indicating that the correct procedures had been carried out to ensure positive outcomes. Each care plan had any associated risk assessments and guides. For example a resident who had a supa-pubic catheter had a clear plan detailing when the catheter had been inserted and how it should be cared for. There had also been a short-term care plan covering a urinary infection. The risk assessments also resulted in appropriate equipment being sought for people, such as pressure relieving mattresses and hoists. During the inspection we witnessed staff moving and handling people correctly. The home had a variety of moving and handling and pressure relieving equipment, including profiling beds. Staff regularly assessed resident’s nutritional needs and tissue viability. The company also had in place an early warning tool that assessed a variety of aspects of the home on a monthly basis including training, wound management and reportable incident recording. The service had a good relationship with the local GP surgeries and because they took people for rehabilitation, community health professionals, including a GP, were frequent visitors to the home. We checked the Medication Administration Record (MAR) sheets for the four residents we case tracked. Medications were appropriately stored in locked trolley’s that were secured to the wall in a locked room on each floor. Monthly deliveries had been appropriately signed into the home and any outstanding medications from the previous month had been carried forward. This ensured that all the medication we looked at reconciled correctly. The MAR charts had been accurately completed with signatures and omission codes where appropriate. Controlled drugs (CD’s) were stored appropriately and all administrations had been recorded with two signatures in the CD register. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 13 The improvement in the medications systems was particularly pleasing as two of the three requirements made following the last inspection were associated with medication. The requirements made at the last inspection had resulted in the head of care and the quality manager carrying out weekly medication audits and identifying any problems and putting in the appropriate training. We were concerned that in one area the morning ‘medication round’ was not completed until 11.00hrs and the lunchtime round started at 13.00hrs. Throughout the inspection we saw resident’s being treated with respect and dignity and offered choices at all times. The AQAA stated, ‘we also have on our staff team a key champion for the Liverpool care pathway for the dying person. We work with them and the doctors to ensure that everything that can be done is done, in accordance with the dying patient and /or their families’ wishes. Our paperwork and methods are in the style of the Liverpool Care Pathway, and the Macmillan nurses and doctors are happy with our methods of work’. Peoples end of life wishes were recorded and it was documented who and when a relative should be contacted in the event of sudden illness or death. St Marys Nursing Home DS0000017693.V375227.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): 12,13,1,4,15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who used the service had the opportunity to maintain important personal and family relationships. Residents did not appear to have control on the size of the portion they were given to eat and as a consequence may have refused food. EVIDENCE: An activity co-ordinator was employed to co-ordinate activities, but any of the staff were responsible for keeping people stimulated and interested by involving them in activities and/or conversation. There was a plan of different activities, including entertainers, reminiscence, games, music therapy, beauty therapy and quizzes for the month ahead. Other activities, that took less organising, were arranged, as people wanted them. The activities took place St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 15 in the communal lounges, or individual’s bedrooms. The activity co-ordinator told us that the resident had been using the garden when the weather was suitable. She also told us that she spent the majority of her time with people in their own rooms, as many people choose not to participate in the group activities. The day before the inspection the residents had enjoyed a visit from a PAT dog. The activity co-ordinator kept records of peoples interests and also recorded how a person responded to a particular activity. She had recently had the opportunity to meet with other activity co-ordinators in the area and exchange ideas. New ideas had been the introduction of exercise using the wii console. One resident said, “there are things happening, but on the whole I prefer to stay in my room and watch TV”. Visitors were welcomed in to the home at anytime. One visitor told us that he came on the bus each morning to give his wife her breakfast and then left her with the staff. Residents were able to handle their own finances if they wanted and were encouraged to make choices about their day. For example when they got up and went to bed, what they wore and what they ate. The inspection spanned a mealtime and it was apparent from the annual quality audit that food and mealtimes were an area of concern. On the day of the inspection we witnessed breakfast and lunch. Lunch was served in the dining areas or to people in their own rooms. The choice was pork cutlet or shepherds pie served with fresh vegetables, followed by fruit cobbler or ice cream. The meals smelt appetizing but we noted a huge amount of wastage and believed it may have been because portion sizes were too big for the majority. We would have liked to have seen staff encouraging residents to eat and asking them if there was a problem with their meal rather than simply throwing away what had been left, and in some cases hardly touched. One resident said when presented with her dessert, “I really cant eat all this”, and it was apparent she was anxious about having such a huge portion. As a consequence she left it where she may have tried to eat a smaller portion. Residents had a drink with their meal and there were drinks available throughout the home. There was evidence that the family of a resident who had cultural needs had met with the chef to discuss the foods he enjoyed and how they could be prepared. It was also apparent that residents had been involved in menu planning following the quality audit that identified some dissatisfaction with the meals provided. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 16 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 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A robust complaints procedure and staff awareness of safeguarding ensured people were kept safe at all times. EVIDENCE: In addition to the Service Users Guide This homes’ complaints policy was displayed in the reception area and was easily accessible to residents and visitors to the home. It confirmed the expected timescales for responses, and advised people of the process if they were dissatisfied with the outcome. We viewed the complaints file. The home had received complaints since the previous inspection. The complaints had all been managed appropriately, and all response letters and the actions taken as part of the investigations were filed for inspection / audit purposes. The acting manager was very positive about complaints being part of a learning process and encouraged people to voice their opinions. There were also a number of compliments about the St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 17 home. The acting manager advised us that he was available for residents or relatives if they had a complaint. Safeguarding issues were clearly recorded, and being reported appropriately to the Local Authority. We had been made aware of all referrals made since the previous inspection, and all had been managed correctly. Documentation indicated that the manager liaises with the safeguarding team as and when necessary, and the home was embracing the Mental Capacity Act including the Deprivation of Liberty. All staff underwent SOVA training as part of their induction and it was updated regularly. The whistle blowing procedure was also clearly displayed. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 18 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 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On the whole the home was clean and tidy and homely, but some communal areas were in need of redecoration and upgrading to make them more homely. EVIDENCE: Each resident had a single bedroom with en-suite facilities. There had been no major changes to the environment since the last inspection but it had been necessary to change the use of one of the communal lounges to a St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 19 physiotherapy area. At one point in the day the remaining lounge on the first floor did look ‘full’. The home was clean and tidy and we did not notice any unpleasant smells in any areas of the home. Bedrooms were redecorated on a rolling programme and as they became vacant. There was also a plan to change carpets to laminated floors as necessary. Where this had been done in had been effective in keeping the rooms free of odour and easier to keep clean. The communal areas, including the corridors were in need of decoration and looked worn. All the residents we spoke to were satisfied with their bedrooms and one said, “I have been able to bring my picture gallery with me”. There were hand washing facilities throughout the home and all the staff were trained in infection control. Laundry staff told us that they had adequate equipment to ensure personal laundry and linen and towels were washed within an appropriate timescale. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 20 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. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A variety of training was offered to all of the staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. EVIDENCE: At the time of the inspection the acting manager informed us that the home was fully staffed and bank or agency staff were only used if additional staff were needed to cover a hospital visit, or the care needs of a particular resident for a limited period. There had been a lot of changes to the staff team over the last two years, but it was believed a more settled time was ahead. The AQAA told us that management were aware of the need for retention of staff. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 21 We examined the personal files of three members of staff. All contained fully completed application forms, appropriate references, induction checklists and training records and certificates. Criminal Record Bureau (CRB) checks had been carried out on all staff, and home office paperwork was present where required. The staff that we spoke to during this visit was confident and competent in their roles, and were able to talk in depth about individual residents needs and the care that they required. Training records indicated that staff attended a variety of mandatory and specialist training, which the acting manager had ensured was kept updated by the use of a robust training matrix. Recent training had been provided either internally, by the local hospital, by the PCT and by the Local Authority. Recent training included physiotherapy training, Deprivation of Liberty training, diabetes, and the use of food supplements, in addition to the training considered mandatory. . The AQAA suggested that less that 50 of the care staff had NVQ level2, but there was an on-going programme of staff undertaking this qualification so it would be improving. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,37,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had processes in place to continually audit and monitor the care provided. EVIDENCE: At the time of the inspection the home had an acting manager in place. The acting manager was a registered manager, who had filled a managerial vacancy at the home in the past, so knew the home. A new manager had St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 23 been appointed as was due to start on the 11th May 2009. However her notice period with her previous employers allowed her to have some time at the home before commencing duties and she was shadowing the acting manager and meeting with staff from the BUPA estates department on the day of the inspection. She was therefore able to be present at the feedback following this inspection. She was a registered nurse with several years experience managing wards and departments and with a special interest in infection control. She told us “I am looking forward to working here and the challenge of a change”. As already described the home had a number of quality audit systems that encouraged stakeholders to put forward their views and sampled the quality of the care provided. Many of the audits were carried out internally by senior staff that were supported by the company’s audit manager who was also visiting the home on the day of the inspection. The home did not hold individual amounts of cash for residents, but if a resident or a family wanted to have money held on their behalf, this was banked and an electronic account set up. Money could be requested and was readily available via the petty cash. Records that we looked at showed that staff supervision and appraisals were being carried out on a regular basis and that supervision was used to determine the staff training programme. The manager supervised all heads of departments, including those who were not care staff such as housekeepers. The deputy then supervised the nurses and the nurses were responsible for supervising the care staff. Records were securely kept but as already detailed staff must take care to complete the records accurately to ensure good care practises. We looked at health and safety documentation, including the fire log and maintenance book. These had been well kept by the maintenance person. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis and some routine visual checks were carried out daily. The last fire alarm check had been the 27th April and the last fire drill 20th February. The maintenance person was also responsible for ensuring routine checks on other equipment such as the hoist and lift were in place. Maintenance issues were being addressed in a timely fashion. St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 24 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 3 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 2 3 St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 25 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. 2. Standard OP19 OP37 Regulation 23 (2)(d) 17(1) Requirement All areas of the home are kept well decorated and as light and airy as possible. Staff must ensure that records are accurately kept. Timescale for action 01/09/09 01/06/09 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 Refer to Standard OP9 OP15 Good Practice Recommendations Care should be taken that medication rounds are evenly spaced throughout the 24 hour period. Food is served in such a way that residents are encouraged to eat a wholesome diet. Where residents leave a portion of their meal they should be asked if they would like an alternative. Staff should continue to be encouraged and supported to attain NVQ’s. 3 OP28 St Marys Nursing Home DS0000017693.V375227.R01.S.doc Version 5.2 Page 26 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. 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. 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