Inspection on 18/10/05 for 5 St Margaret`s Gardens

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 St Margaret`s Gardens 21/05/09

5 St Margaret`s Gardens 24/05/07

5 St Margaret`s Gardens 25/05/06

5 St Margaret`s Gardens 09/05/05

5 St Margaret`s Gardens 20/12/04

5 St Margaret`s Gardens 20/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Margaret`s Gardens (5) Melksham Wiltshire SN12 7BT Lead Inspector Malcolm Kippax Unannounced Inspection 18th October 2005 12:20 St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Margaret`s Gardens (5) Address Melksham Wiltshire SN12 7BT 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) 01225 709691 Ordinary Life Project Association Ms Jacqueline Mitchell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2005 Brief Description of the Service: 5 St Margarets Gardens is one of a number of homes that are run by the Ordinary Life Project Association (OLPA). The home is located in a residential area on the outskirts of Melksham. 5 St Margarets Gardens is a two storey detached house that is in keeping with the neighbouring properties. Each service user has their own bedroom. One of the service users has a bedroom with an en-suite bathroom on the ground floor. The other accommodation includes a lounge, dining room, kitchen, an upstairs bathroom and a separate W.C. There is a large garden at the side of the property. Mrs Mitchell manages a permanent staff team of support workers. At least one member of staff, or the manager, is working throughout the day. The service users attend day activities in the community. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection began at 12.20 pm and lasted for five hours. One service user was at home when the inspection started and the other service users returned from their day activities later in the afternoon. Each of the four service users was met with. Two staff members were working at the time. Initially, a staff member spoke about an incident that had arisen two days before. This was later discussed with the OLPA Chief Officer. The communal rooms and the domestic areas were seen. Records were examined, including meeting minutes, health & safety, medication and assessments. What the service does well: What has improved since the last inspection? What they could do better: The laundry area remains unhygienic and is not a nice place for the service users and staff to use. The home was required to improve this at the last the inspection, although there has been no change. The laundry area must be properly cleaned by 28 October 2005. Risk assessments have been undertaken in the past, although several of these need to be reviewed to ensure that they remain up to date and take into account the service users’ current circumstances. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (Standards 1 and 4 were inspected and met at the last inspection.) Pre-admission assessments of a new service user have provided relevant information for staff. EVIDENCE: A new service user had moved into the home since the last inspection. Staff members said that this had now been made a permanent move. A personal file had been set up for the service user. This included a ‘Personal Profile’ form and a copy of the service user’s community care assessment. Other information included a Statement of Needs and a Speech and Language Therapy Assessment report. The staff members spoken with were familiar with the main areas of the service user’s needs, as recorded in the assessments. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 (Key standard 9 and standards 6 and 8 were inspected and met at the last inspection.) A new service user does not yet benefit from having a care plan that has been agreed in the home and shows their personal goal and needs. Opportunities and support is given to help service users make decisions about their lives. EVIDENCE: The new service user’s records included a care plan that had been written as part of the assessment process prior to the move to 5 St. Margaret’s Gardens. This did not cover all aspects of personal and social support and healthcare needs. Staff members were relying on the assessment records for information, although these do not show how the service user’s needs and wishes are to be met and the action that should be taken by support staff. The other service users’ care plans were not looked at on this occasion. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 10 Minutes of the tenants meetings showed that decisions are made in such areas as social events and menus. Service users make decisions in review meeting about their planned day activities. There is a cat in the home, which is owned and looked after by one of the service users. During the inspection, one service user had chosen to help prepare the tea meal with a staff member. Advocacy for one of the service users had been discussed at a recent staff meeting. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 16 (Key standards 12, 13 and 17 were inspected and met at the last inspection.) Service users have the opportunity to meet people in the community and staff members are promoting good relationships within the home. Daily routines are geared around the service users’ activities and wishes. EVIDENCE: Service users have regular activities during the week when they meet with people outside the home. During the afternoon of the inspection, one service user left to go to a part-time job that he has locally. The service user does this journey independently and said that he enjoyed the job and meeting with people there. Two other service users returned from their day activities by travelling on the bus together. Contact with family members varies. One service user sees her parents regularly and had recently enjoyed spending her birthday with them. Another service user regularly goes out with a brother. Relationships within the home have been discussed at ‘tenants’ meetings in order to help resolve issues that St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 12 arise between individuals. The minutes of tenant and staff meetings showed the involvement of staff in supporting service users with their relationships. Two service users are particularly close and like to spend time in each other’s rooms. They also spend time together outside the home, for example going to the local swimming pool. One service user said that sometimes a difficulty arose with another service user about channels being changed on the television that people watch in the lounge. It was agreed that this would be a useful thing to discuss at one of the tenants meetings. One service user spoken with said that she could get up and go to bed when she wished. Service users have keys to their own rooms. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 (Key standards 18 and 19 were inspected and met at the last inspection.) Service users receive the support that they need with managing their medication. EVIDENCE: There were suitable facilities in place for the safekeeping of medication. Staff members administer the medication, as this is not something that service users are assessed as being able to do themselves. A stock record of medication was being kept and the records of administration were up to date. These were contained in a medication file that also included medication profiles and drug information cards. Drug administration is included as a subject in the OLPA training programme. The training is provided ‘in-house’ and the involvement of an outside specialist is also recommended. This will help to widen the staff team’s knowledge of medication and drug use. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. (Standards 22 and 23 were inspected at the last inspection. Standard 22 was almost met and standard 23 was met.) EVIDENCE: St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 (Standards 24 and 30 were also inspected at the last inspection and almost met.) The accommodation is meeting the service users’ needs. The new kitchen looks modern and will be a big improvement. The laundry area needs to improve so that service users and staff can use the machines in cleaner surroundings. EVIDENCE: Comments from service users indicated their satisfaction with the accommodation. They like to use their own bedrooms but also spend time in the lounge. A separate dining room provides a useful space for other, quieter activities. Some of the service users’ community activities are within walking distance of the home. The accommodation generally is homely and domestic in character. Service users said that they liked the look of the new kitchen, which was being refitted at the time of the inspection. Most of the new units were in place. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 16 In contrast, the laundry area continues to look unhygienic and be in a poor state. A lack of basic cleaning has meant that cobwebs and dust have been left to accumulate. The washing machine and drier were standing on a wet and rusting drain inspection cover. A freezer positioned next to the machines was in a poor condition. The handle was missing and a door seal was damaged and had mould on it; the freezer should have been cleaned and repaired before getting into this condition. There was a requirement at the last inspection for the laundry area to be cleaned and a hygienic surface maintained under the washing machine. It was also recommended that appropriate facilities are provided for hand washing and drying after the washing machine has been used. The requirement and recommendation have not been met. An immediate requirement notice was issued in respect of the condition of the laundry area. Staff members said that a gardener was now helping to maintain the garden, the appearance of which was much improved since the last inspection. It was reported at the last inspection that service users need to spend their own money on garden furniture and it was recommended that in the future alternative means are found to meet the costs of garden and outside leisure equipment. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 (Standard 33 was inspected and met at the last inspection.) Staff members know the service users well and most have achieved or are undertaking a relevant qualification. Staff members have access to a range of relevant training activities although the standard for induction is not being met. This means that staff members who are new to learning disability services do not receive the type of induction that will be of most benefit to service users. EVIDENCE: The two staff members said that they were near to completing NVQ at level 2 and that another staff member had achieved NVQ at level 3. An example of a staff member’s ‘Staff training and development’ record was looked at. This showed attendance on courses that had been arranged through OLPA in first aid, food hygiene, fire training and drug administration. A course on ‘’Rights, Freedoms and Responsibilities’ had also been completed. There is an induction programme for new staff members. It has previously been recommended that L.D.A.F. accredited training is used for the provision of induction and foundation training. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 18 No new staff members have been recruited since the last inspection. There is a written staff rota. One member of the staff team was on long-term sick leave. Relief staff and agency carers are being used to cover for this. A staff meeting had been held on 16 September 2005. The minutes showed a good focus on the service users, with a range of topics having been discussed in relation to each person. A service user commented that she got on well with staff. There was a good rapport between staff members and two other service users when they returned home from their day activities. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home has an experienced manager who is undertaking relevant qualifications that are expected of a registered manager. Evidence of up to date self-monitoring and action based on a system of quality review is not available in the home. Risk assessments and practical measures are in place, which help to maintain a safe environment. However, a lack of up to date information may compromise the service users’ wellbeing. EVIDENCE: The registered manager has been in post for a number of years and has previous experience of other care services. Staff members said that the manager was progressing with NVQ at level 4. The staff members present were not aware of a file or information in the home about quality assurance. A Business and Action plan, April 2003 –2004, was St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 20 seen on the home’s maintenance file. This included an analysis of strengths and weaknesses. Although information gained through quality assurance may be kept and analysed within the OLPA office, there needs to be documentation in the home, which shows the outcome of current quality assurance initiatives and up to date action plans in respect of the home. The home has a health & safety file, which includes guidance notes, accident reports and servicing records. Some other service records were also contained in the maintenance file. Risk assessments were contained in a separate file. Several of these had not been reviewed since the first half of 2004. A fire risk assessment was undertaken in September 2003, is in need of review, as it does not include smoking as a hazard. The home has a policy in which staff members can smoke in the laundry area/garage. A lone working assessment was carried out in June 2004. Staff members said that guidance about lone working had recently been received in the home. The assessment should be reviewed in the light of this guidance and recent incidents that were discussed during the inspection. Risk assessments had not been completed in respect of the new service user and staff members said that as a result there were some activities, e.g. swimming that the service user could not yet participate in. The home’s fire log book was up to date. St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X N/A 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Margaret`s Gardens (5) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000028372.V259354.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement Each service user must have a care plan that covers those items specified under Standard 6of the National Minimum Standards. The laundry area needs to be cleaned and a hygienic surface maintained under the washing machine (this requirement from the last inspection has not been met). Documentation produced in connection with quality assurance and annual development must be up to date and available for inspection. The risk assessment in respect of fire must be reviewed and include smoking in the home as a hazard. The risk assessment in respect of lone working by staff must be reviewed in the light of current guidance and recent events in the home. Risk assessments in respect of the new service user must be completed. Timescale for action 11/11/05 2. YA30 23 28/10/05 3. YA39 24 11/11/05 4. YA42 13 04/11/05 5. YA42 13 04/11/05 6. YA42 13 11/11/05 St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 23 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 YA20 YA30 Good Practice Recommendations That staff members have the opportunity to receive training in medication and drug use from an outside, specialist source. That appropriate facilities are provided for hand washing and drying after the washing machine has been used (this recommendation from the last inspection has not been met). That Learning Disability Award Framework (L.D.A.F.) accredited training is used to provide staff with the underpinning knowledge that they need, e.g. when completing N.V.Q. That risk assessments are reviewed at least annually (the risk assessments must be reviewed more frequently if any significant changes arise). That the contents of the health & safety and the maintenance files are reviewed in order to ensure that similar records are kept together within appropriate sections. 3. YA35 4. 5. YA42 St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margaret`s Gardens (5) DS0000028372.V259354.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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