Inspection on 08/08/05 for Margaret House

This inspection was carried out on 8th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Margaret House 17/12/08

Margaret House 10/01/07

Margaret House 25/01/06

Margaret House 01/03/05

Margaret House 22/06/04

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

CARE HOMES FOR OLDER PEOPLE MARGARET HOUSE 221 Manchester Road Burnley Lancashire BB11 4HN Lead Inspector Marie Dickinson Unannounced 08/09/2005 10:00 am 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 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 Older People. 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. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Margaret House Address 221 Manchester Road Burnley Lancashire BB11 4HN 01282 423804 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Gordon Fell Care Home (CRH) 11 Category(ies) of Dementia - over 65 years of age DE(E) = 6 registration, with number Mental disorder, excluding learning of places disability or dementia MD = 5 Mental Disorder, excluding learning disability or dementia - over 65 years of age MD(E) = 6 MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Within the overall total of 11, a maximum of 5 named service users who fall into the category of Mental Disorder Within the overall total of eleven, a maximum of 6 service users who fall into the categories of either Mental Disorder Elderly or Dementia Elderly Should any of the named service users referred to in condition 1 above be no longer resident in the home or reach the age of sixty five, registration should revert to the original registration of the home. 11 MD(E), 11 DE(E) Date of last inspection 1 March 2005 Brief Description of the Service: Margaret House is registered with the Commission for Social Care Inspection to provide personal care and accommodation for 11 people, whose main care needs are mental health difficulties. The home is located in a residential area of Burnley and is adjacent to Scott Park. There are pleasant accessible garden areas to the front and sides with a lawn area to the side and rear of the home. There is a bus stop near the home, on route to the town centre. Accommodation offered is in single and one double room, fitted with an emergency call system. The home was furnished and decorated to a domestic style. Mr Fell the owner, manages the home on a day-to-day basis. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, and involved looking at written information and records relating to residents and staff employed in the home. Time was spent talking to the people who live at the home, a visitor and staff on duty. Observations were made of the care provided in line with Minimum Standards and some residents talked about their personal experiences of life for them in the home. What the service does well: What has improved since the last inspection? MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 6 Parts of the home have been decorated and new furniture purchased. Some resident’s bedrooms had new floor coverings. The new windows being fitted during the last inspection are now finished. A games room has been created for residents to play pool, which they said they enjoy. As requested during the last inspection staff files have been completed correctly. What they could do better: 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. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 The use of a question and answer letter informing people about life at the home was beneficial. Proper use of assessment information had identified that the home was able to offer care services for people making enquiries about the home. The assessments also contained sufficient information to write a plan of care. Procedures were in place to ensure all residents are admitted in a proper manner. EVIDENCE: People living at the home had received a welcoming letter, which included questions they may want to ask. It was easy to read and useful for anyone feeling anxious about making a decision to live at the home. Everyone had received a contract on admission. Records showed that residents had been assessed before they came to live at the home. The assessments were clearly written, showing what support was needed. It was clear residents and where possible relatives had been involved in this process. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 9 The range of needs of residents had been considered, and staff were trained in looking after residents with a variety of needs such as dementia care. Records also showed that the changing need of residents was responded to and advice taken from other professionals such as social worker, district nurse and psychiatric healthcare workers. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. Care plans were used to help staff to care for residents in a proper manner. Because they were reviewed this allowed for residents changing needs being dealt with promptly. Residents were satisfied that their needs were met and they considered staff respected their privacy. Relatives and visitors to the home were confident how care staff carried out their duties. Staff were professional in ensuring people unable to express themselves were treated with respect. EVIDENCE: The staff said they were involved with care planning and work to a key worker system, whereby they take on particular responsibilities for individual residents. Care plans referred to residents assessed need. These included health, personal and social care needs. There was evidence that residents were involved in regular reviews. The resident’s healthcare and mental health care needs were also identified and staff confirmed how these needs were met. This included visits from a chiropodist and their doctor when necessary. The staff and Mr Fell supported visits to hospital appointments. Support was also given for continence management. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 11 Difficulties residents had were looked at in detail and risk assessed. These assessments were of a good standard with clear instructions for managing the risks identified. Residents were of the opinion that care staff respected their right to privacy, especially when they were attending to their personal care. This was also observed during the inspection. Residents who had difficulty in saying what they wanted were treated with respect, and care had been given to their appearance. Staff helped them to be involved in the inspection as much as possible. Relatives written responses confirmed they were kept informed of matters, which involved their relative. One relative visiting during inspection said staff were ‘very good and caring, treating his father with respect’ and were ‘always polite’. A professional who visited the home forwarded a written response to the Commission; considered residents in the home were ‘well cared for’. Medication records were up to date and correct. Medication was managed correctly. Staff responsible for dealing with medication were trained. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Activities in the home were provided for each resident in a personal way. Weekly planners were used for this purpose. Resident’s lifestyle experience of living in the home was generally to their liking. Visitors were made welcome. Catering arrangements were to the resident’s satisfaction. EVIDENCE: Activities for residents were arranged individually and recorded on a weekly planner. Some were organised activities such as attending social clubs and outings. Staff took residents to Church on Sunday. Residents had holidays away from the home at their request. One resident enjoyed helping with household tasks for example dusting. It was clear residents lifestyle in the home was to their liking. They said they enjoyed being involved in everyday household routines such as shopping. Residents said the general routine in the home suited them. There were no unnecessary rules to follow. They could please themselves when they get up or when they went to bed and staff were available should they need them. Staff were observed as being thoughtful towards residents with dementia, who were included in conversations and activities. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 13 One visitor in the home said staff made him welcome. He visited anytime he wanted. Comments from residents indicated the food was good. Staff took turns to cook and residents said they discussed menus at their meetings. There were ample supplies of groceries and fresh produce to use. Residents were given choices at meals and records showed alternatives were also given. The mealtime was relaxed and although mealtimes were set times they were also flexible to suit individual needs. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The complaints procedure was clear and accessible for residents and visitors to the home such as relatives. There were policies and procedures in place to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: A complaints procedure for residents to use was given to them when they came to live at the home. This was confirmed by comments received at the Commission from residents and visitors. A visitor said he would have no problem expressing any concern he had to the owner or any staff member. He felt it would be taken seriously and dealt with properly. There were no recorded complaints since the last inspection. Staff said that abuse procedures and whistle blowing training had been given to them. They discussed their responsibility to protect residents from abuse and considered it their duty to act in accordance with abuse procedures if necessary. A condition of employment for staff in the home prevents them having any financial gain from residents. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26 The home was maintained to a relatively good standard, and residents lived in a comfortable and homely environment. A good standard of hygiene was also achieved. EVIDENCE: The home was furnished and maintained to a relatively good standard. There was evidence of continuing improvement with redecoration and new furniture. Mr Fell discussed future plans for more decorating and general upgrade. Residents said they liked their bedrooms. Furniture provided and fittings were maintained and adequate for the residents needs. In some rooms residents had their own furniture. Residents could be involved in choice of colour schemes in redecoration. Comments noted included ‘very clean and homely atmosphere’. The landing carpet required easing out to remove slight rippling. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 16 All of the residents have use of a call bell to summon the staff for assistance. The ground floor bathroom had a walk in shower. The water temperature was controlled to prevent people from accidental scalding when bathing. To further protect residents, the hand washbasin in the bathroom on the upper floor should also have some control on temperature. This was discussed with a plumber during inspection. To benefit staff not having to go into the bathroom to wash their hands, hand washing or hand-cleansing facilities should be provided in the staff toilet. A good standard of hygiene was observed in the home during inspection. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The level of staffing was good. Recruitment and selection procedures were satisfactory. Residents had confidence in the staff working at the home. Training provided and attended by staff was good and offered a wide range of topics. Staff received regular supervision. EVIDENCE: The home was fully staffed during the inspection. Rotas showed sufficient staff were employed at the home to make sure all residents’ needs were met. The residents were very happy with the staff in the home. Staff had worked there for a long time and residents They said staff were ‘very good’ and ‘did their best to satisfy’. One comment described staff as ‘professionals’. Staff files showed recruitment checks to be complete. All staff files had been brought up to date since the last inspection. Staff had attended training, and the percentage of staff having completed a national vocational qualification in care level 2 and above was approximately 80 exceeding the 50 target. Staff said they enjoyed training and were supported to develop their career in care. They confirmed they received supervision regularly. On appointment members of staff were issued with a contract of terms and conditions of employment. Staff said they had received a copy of the General MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 18 Social Care Council’s code of practice and conduct. All members of staff had a job description. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,38. The home was generally well organised and managed efficiently. Guidance and support was given to staff, which contributed towards the resident’s quality of life experience in the home being positive. Resident’s personal money was managed well. Good practice was observed in safe working procedures. EVIDENCE: The registered provider Mr Fell manages the home with the support of senior carers. Mr Fell is a qualified nurse. He has continued in professional training, having completed the Registered Managers Award. The means of seeking residents and staff views about the home was both formal and informal with residents and staff meetings. Views of residents and other people from anonymous questionnaires however should be sought. The findings of this survey should then be published and made available for people to look at, and a copy sent to the Commission. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 20 Staff confirmed they received routine formal supervision. Staff said they felt supported in their work, and during supervision they were given an opportunity to discuss and raise issues related to their work. Residents, relatives and staff expressed general satisfaction about the home. Staff said they were given guidance and support. Routines for staff in the home were established, and good teamwork was evident. Money held for resident’s use was managed correctly. Balances were correct and receipts kept. The health, safety and welfare of residents and staff had been considered. MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 2 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x 3 3 x 3 MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 22 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard Good Practice Recommendations MARGARET HOUSE F57F07 9578 Margaret House V243698 080905 Stage 4 doc.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit 4, Petre Road Clayton Business Park Accrington BB5 5JB 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. 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