Latest Inspection
This is the latest available inspection report for this service, carried out on 29th May 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 Marys Nursing Home.
Annual service review
Name of Service: St Marys 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: Rob Cooper Date of this annual service review: 0 9 0 6 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service
Address of service: Ednaston Ashbourne Derby Derby Derbyshire DE6 3BA 01335360254 Telephone number: Fax number: Email address: Provider web address:
kathrynsmith@btconnect.com Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category physical disability Conditions of registration: 35 places for OP, E & PD Institute of our Lady of Mercy Number of places (if applicable): Under 65 Over 65 0 1 35 0 Have there been any changes in the ownership, management or the No 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 is a 35-place care home with nursing. The Home is able to offer respite and short-term convalescence care, and is also suitably adapted to accommodate wheelchair users. The Home provides 24-hour personal care with nursing. Qualified nurses are on duty each shift, and additional management on-call arrangements are in operation outside office hours. Care staff are offered training to levels 2 and 3 National Vocational Qualification (NVQ). Additional in-house and mandatory staff training is provided.
Annual Service Review Page 2 of 6 The Home offers 29 single en-suite bedrooms and 3 shared en-suite bedrooms. The Home also has a passenger lift between the ground and first floor. Residents have access to the large, attractive, well maintained grounds. The building is well maintained. Decoration and furnishings are of a very high standard throughout. The Residents also have access to a private chapel. The charges made for a room at St Marys Nursing Home range from £525.00 a week to £605.00 a week, dependent on the bedroom provided and the needs of the particular Resident. A copy of the Commissions inspection report is available from within the Home. Annual Service Review Page 3 of 6 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 that we have received from St Marys, or asked them for, since the last key inspection. This included: The Annual Quality Assurance Assessment (AQAA) that was sent to us by the service, and was received in April 2009. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some statistical and numerical information about St Marys. We sent out five questionnaires to people who live at the care home, five to relatives and five to staff. At the time of writing this annual service review we have received four from people who live at the home, four from relatives and four from members of staff. Information we have about St Marys on the QA system has been reviewed, including any complaints or concerns that have been raised. We reviewed the Regulation 37 forms that have been submitted - these are a legal requirement and tell us about incidents that have affected the well being of the people living at the care home. The last key inspection report and the inspection record have been reviewed The service folder was reviewed for any other relevant information. We also looked at any relevant information that we have received about St Marys from other organisations. We looked at what other people have told us about the service. What has this told us about the service? The AQAA was returned within the time scale asked for, and had been completed in a professional manner, providing all of the information asked for, and in sufficient depth to allow judgements to be made. Among the improvements to the service identified in the AQAA were: We have constantly assessed the provision of care by keeping residents informed of any changes plus their representatives. We have increased the amount of profiling beds and pressure relieving equipment plus training from Tissue viability. I have also implemented Standard Five-Tissue viability. We have been more proactive with regards to implementing risk assessments for those at risk of falling with the introduction of crash mats and referring promptly to the Mental Health services. We have examined ways of involving carers more in the activities to aide the work of the activities coordinator especially in residents with cognitive impairment, 1:1 relationships between staff and residents on a continual basis has improved residents awareness of environment ability to communicate non-verbally and verbally. Facilitate training in different ways such as role play, off site training and increased provision of dementia awareness training. The Commission has not received any complaints regarding this service since the last key inspection. In their AQAA the care home stated they had not received any complaints in the last twelve months, and no safeguarding adults referrals have been made in the last twelve months. Comments received in the questionnaires from people who live at St Marys included Annual Service Review Page 4 of 6 the following with regard to what the home does well: Very thoughtful, I enjoy the garden on sunny days, The staff are very caring, Care, communication, being available to talk to me and listen to my comments, clean and caring staff. The following comments were also made in relation to what the home could do better: More staff on shift, improve the choice of food, Evening meals could be improved to give variety or hot options. Comments received in the questionnaires from relatives included the following: The home is very clean, the staff are very caring, The staff respect each individual and their needs, provide activities on a regular basis, involving participation and social interaction, good quality home cooked food. More staff would allow greater interaction with patients. Comments received in the questionnaires from staff included the following: The home provides a real caring environment, Residents are treated with courtesy and respect, Deliver care, liase with relatives, promotes holistic care, I enjoy working in the home, and feel the residents do get a good standard of care from all levels of staff. Provides a good care service. Each resident is an individual and there is at times difficulty in meeting each individual need. I feel the home does well, but there is always room to improve services to our residents. We have received seven Regulation 37 forms during the past twelve months to report any notifiable incidents involving people who live at the care home or the staff, these were routine, and did not initiate any further enquiry. At the last key inspection this care home was rated as being an excellent service. We have not received any other information from other agenies about St Marys There are no ongoing concerns about the quality of care St Marys offers, and a review of the documentation that has been received does not highlight any issues that need to be immediately addressed. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and we will carry out a key inspection by 30 April 2010. However, we can inspect the service at any time if we have concerns about the quality there or the safety of the people using the service Annual Service Review Page 5 of 6 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:
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 copy of the findings 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Annual Service Review Page 6 of 6 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
