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Inspection on 09/11/05 for Margaret House (Barley)

Also see our care home review for Margaret House (Barley) for more information

This inspection was carried out on 9th November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

It is hard to find fault with Margaret House which, although an old building, is well maintained and always looks attractive. The newly refurbished conservatory looks beautiful as do the gardens, and the residents clearly appreciate the environment. One resident described the meals as "beautiful" and they are attractively served and there is a good choice of food. The residents and staff have mutual respect for one another and staff provide a wide range of activities. The Manager is also commended for the high standards of management in all the areas she maintains. The home is run for the benefit of the residents at all times and provides above average facilities within a homely atmosphere and is part of the village community and well supported by that community and friends and families in general.

What has improved since the last inspection?

A new system has been installed for the administration of medication and further decoration has taken place throughout the home. A new Deputy Manager has been appointed and there is a good working relationship between this senior and the Manager.

What the care home could do better:

There is only one Requirement, that the fire door to the dining room must not be wedged open.

CARE HOMES FOR OLDER PEOPLE Margaret House (Barley) Church End Barley Nr. Royston Hertfordshire SG8 8JS Lead Inspector Pat House Unannounced Inspection 9th November 2005 11.00a X10015.doc Version 1.40 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 Margaret House (Barley) DS0000019458.V265282.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 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 (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Margaret House (Barley) Address Church End Barley Nr. Royston Hertfordshire SG8 8JS 01763 848 272 01763 848 867 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) Mr T Kelly Ms Margaret Guzman Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: Margaret House is a large Victorian detached house, which has been converted to provide care for 28 elderly people. There are three floors connected by a passenger lift and staircases. The conversion and extensions to the house have been sympathetically made and the house retains elegant period features whilst being suitable for its use as a care home. All the bedrooms are single occupancy and eight now have en-suite facilities. There is parking at the front of the house, behind a large brick wall. The grounds are extensive and beautifully kept and there is a large conservatory with lovely views. The home is situated in the quiet village of Barley, not far from the town of Royston. The village has a Post Office, shop, Health Centre and Church and Margaret House forms an integral part of this community. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day with one inspector. The Manager was present during the visit as was the Deputy Manager, who had been appointed since the last inspection. A brief tour of the home took place and service users and staff were spoken to. The mid-day meal was seen and some records were checked. What the service does well: What has improved since the last inspection? 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 (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 6 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 Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 2. Standard 6 does not apply to this home. Each service user is issued with a written contract so that they are clear about the terms and conditions, which apply to their residency in the home. EVIDENCE: All service users are issued with a contract when they enter the home. These documents list all appropriate information, including details of what is included in the fees and the room to be occupied. All other standards were fully assessed and met at the last inspection. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 9, 10 and 11. Standards 7 and 8 were assessed and met at the last inspection. The home’s policies and procedures for medication administration and support at times of illness, ensure that service users’ health and well being is promoted. Residents are treated with respect from the staff and feel confident their privacy will be respected at all times. EVIDENCE: There is a new system for the administration of medication in operation in the home. There is now a lockable medication trolley from which the drugs are administered, while separate stocks are stored in a locked cupboard in the office. Medication in the trolley was dated when it was opened and times of opening were also recorded. There were no gaps on the record sheets and most totals of medication were being carried forward. Two service users selfmedicate at present and risk assessments and safeguards were detailed. Currently the medication record sheets are not pre-printed, and the pharmacist is issuing pre-printed labels. This is not a recommended procedure and the Manager was advised to discuss this further with the pharmacist. Service users spoken to confirmed that all the staff treat them with respect and always knock and wait before entering a bedroom. There is a phone available in the office for the use of service users, although many have private telephones in their rooms. Residents spoken to said they Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 9 saw the doctor in private or with a staff member if they chose. The home has a policy on Death and Dying, which staff were aware of. Staff spoken to said that service users and their families were given all possible care and support at times of illness. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12, 13, 14 and 15. The wide choice of activities and food in the home help to provide a stimulating and satisfying environment for service users, while procedures in the home and contact with the local environment help the residents to maintain their independence. EVIDENCE: As at previous inspections, the residents said they enjoy a wide variety of activities and had had Halloween and Bonfire parties in the past two months. Staff at the home also take small groups of service users in turn, out to lunch every month and the residents clearly enjoy this. The home is holding a Christmas Bazaar in November, and service users have been making decorations and items to sell at this event. Families and the local community are invited to the Bazaar. The annual Christmas party will be held in December and friends and families are invited to this. In the summer the staff and residents entertained over 100 people to a summer barbeque in the gardens. During the visit it was pleasant to talk to residents in the lounge, where the television was not on, and where the armchairs are arranged in groups and not all around the walls. Service users said they could have visitors at any times and were aware of advocacy services and said there were leaflets available to access this service if they needed. One resident said she had chosen to change her own bed linen and her family did her washing and this was because she thought of her bedroom as her own Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 11 private accommodation. The mid-day meal was served during the visit and the meal was well presented, hot and nutritious. The tables were laid with flowers and service users had drinks of juice, wine and lager, according to choice. Jugs of drinks and glasses were set out in the lounge and in bedrooms. There was a four week menu on display in the conservatory and this showed a choice at each meal and a cooked tea each day and also said anyone could ask for alternative food if they wished. Residents confirmed the food in the home was always of a high standard. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 17. Standards 16 and 18 were fully assessed and met at the last inspection. Policies and practices in the home protect the legal rights of service users. EVIDENCE: All residents in the home are registered to vote at elections and know that advocacy services are available if they require this. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19, 25 and 26. All other standards were previously assessed and met. Service users live in very comfortable surroundings which are kept hygienic and well maintained and decorated, and which add to their well being. EVIDENCE: There is a continuous programme of redecoration going on in the home which looked bright and clean during the visit. The conservatory has been completely refurbished and subdued lighting has been installed. Bedrooms were being redecorated during the visit and a new carpet has been ordered for the entrance hall. Radiators are covered and can be individually adjusted and all bedrooms have door locks and contain lockable space. One service user said they held their own door key and care plans have notes that this provision has been offered. The gardens looked very attractive and are accessible to all with ramps and grab rails in place. There is emergency lighting throughout the building and the hot water was being delivered at safe temperatures. The home has a contract for clinical waste collection and there are paper towels and liquid soap dispensers in bathrooms to promote infection control. The laundry was clean and the floors and walls are impermeable. However, some upgrading of this area will be needed in the not too distant future. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 14 Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Service users are protected by the home’s procedures and staff have the necessary skills to meet their needs. EVIDENCE: These standards were all assessed and met at the last inspection and were briefly reassessed at this visit. As always there were good levels of staff on duty and residents confirmed this was always the case. Staff confirmed they have regular meetings to which domestic staff are invited and that regular formal supervision takes place. Records of supervision were seen. All appropriate training was up to date and since the last inspection all staff have taken part in Dementia Awareness training. All staff have also received training in Adult Abuse and Whistle Blowing. The home now has now achieved the target of having at least 50 of care staff trained to NVQ level 2 or above. Recruitment files for some new staff were checked and evidence of all appropriate checks was in place. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38. Service users benefit from living in a well managed home where procedures for maintaining records, promoting safety and supervising staff ensure that the welfare of service users is promoted at all times. EVIDENCE: The Registered manager has completed the Registered Manager’s award and is an Assessor for NVQ training. The Manager is also doing NVQ 4 training at the moment. All staff and service users spoken to praised the Manager and senior staff and said they were always available to give support and advice. The Manager confirmed there were good working relations with the Proprietor who was usually present for residents’ meetings and to ensure the home was well maintained. The Manager has a system in place for Quality Assurance and there has surveys returned from residents and families. The Manager also monitors accidents and incidents in the home and the outcomes from supervision and meetings all feed in to recommendations for future budgeting. After the new Deputy manager was appointed, she was introduced to service Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 17 users at a residents’ meeting and after another residents’ meeting the home’s menus had some changes introduced. A certificate for insurance cover for the home is displayed in the hall and all financial recording is well documented. Records are kept securely and staff said that service users could have access to their records whenever they wished. There had been no complaints made to the home although there is an empty Complaints Book. Servicing records were up to date and staff confirmed there were regular fire drills in the home. The CSCI receives all appropriate information required by Regulation 37 of the Care Homes Regulations about accidents and incidents in the home. There was just one fire door being wedged open during the visit and this was the door to the dining room. A Requirement has therefore been made that this door must not be wedged open. Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 18 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 x 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x 3 x x x x x 3 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 3 3 3 3 3 3 2 Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 23(4) Requirement The Registered Provider must ensure that no fire doors in the home are wedged open. Timescale for action 09/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Margaret House (Barley) DS0000019458.V265282.R01.S.doc Version 5.0 Page 21 - 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. 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