Inspection on 10/05/05 for St Margaret`s

This inspection was carried out on 10th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Margaret`s 10/06/08

St Margaret`s 18/09/07

St Margaret`s 11/07/06

St Margaret`s 20/10/05

St Margaret`s 12/10/04

St Margaret`s 29/06/04

St Margaret`s 08/03/04

St Margaret`s 19/01/04

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

CARE HOMES FOR OLDER PEOPLE St Margarets Mylord Road Fraddon St Columb TR9 6LX Lead Inspector Mike Dennis Unannounced 10 May 2005 09:30 a.m. 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. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Margarets Address Mylords Road Fraddon St Columb Cornwall TR9 6LX 01726 861497 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) Blakeshields Limited Mrs Sandra McFarlane CRH 28 Category(ies) of OP, 28 TI, 5 PD 5 registration, with number of places St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users to inlcude up to Service users to include up to Service users to include up to Total number of service users 28 adults of old age (OP) 5 adults with a terminal illness (TI) 5 adults with a physical illness (PD) not ot exceed a mximum of 28 Date of last inspection 12th October 2004 Brief Description of the Service: St. Margarets is situated on the main road within the village of Fraddon. It is a care home with nursing, and is currently registered for 28 service users within the category of old age not falling into any other category. This includes service users who may have physical disability (5), or be terminally ill (5). The home provides day care for 2 service users up to twice a week. A trained nurse is on duty over the 24 -hour period. There are communal facilities comprising a newly completed dining room and various lounge areas. A passenger lift provides access to the first floor for those with mobility problems. The majority of rooms offer single accommodation. The home has recently been extended to provide an additional 6 en-suite rooms. Other building work to provide a new kitchen, lounge /hallway area is now complete. There is car parking to the front of the building. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 10th. May 2005 over a six hour period. The inspector met with the Registered Manager, the Deputy, and staff on duty, and had specific conversations with 5 service users. During the course of the day the inspector observed the service users being attended to by staff and noted that they were treated with due respect. Service users informed the inspector that their expectations of being in a care home were being met and that they were satisfied with the services offered. Various records, policies and procedures were inspected and found to be satisfactory. The inspector visited all parts of the building and noted a satisfactory standard of hygiene. Alterations and improvements have occurred to the premises since the last inspection and these are now all but complete providing additional and improved facilities. On arrival at this unannounced inspection, the inspector noted a new member of staff being inducted into the fire safety routines which was being delivered in a professional and competent manner. The last inspection report highlighted a number of Statutory Requirements. It is pleasing to report that the newly appointed manager has already rectified the majority of those deficits. What the service does well: What has improved since the last inspection? The overall referral route is now undertaken in a more consistent and professional manner from initial referral to pre-admission assessment to initial plan of care to admission to implementation. The overall infrastructure of the home is improving. The environment has improved, the care delivery has improved and training has improved. Food preparation areas are better equipped leading to wholesome food with choices available St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 6 The manager appears committed to taking the home forward to achieve best practice. 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. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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 St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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) 1,3,5 and 6 Prospective service users are provided with the information they require in order to make an informed decision about admission to the home. Service users are now fully assessed prior to admission to the home. Prospective service users visit the home to assess it’s suitability prior to ad mission. This home does not provide Intermediate care. EVIDENCE: A Statement of Purpose and Service User Guide is available. These documents have been recently reviewed. Service users informed the inspector that they had knowledge of these documents and they were seen be available in different parts of the home. Four service user files were inspected and case tracked. All contained information pertaining to pre-admission assessment. On the day of inspection a referral was received by telephone and the manager made arrangements for a pre-admission assessment to take place the following day. The policies and procedures of the home allow for prospective service users and their relatives to visit prior to admission to assess the quality, facilities and St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 9 suitability of the home. On the afternoon of the inspection a gentleman visited with his wife for this purpose. Standard 6 is not applicable as the home does not provide intermediate care. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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 and 11 The health care needs of service users are identified, planned for and met. Service users are treated with dignity and respect. Medication policies and procedures are comprehensive and followed by Trained staff. EVIDENCE: The care planning system has been redesigned by the manager since the last inspection. The new system contains all the relevant information required. Care staff maintain the personal and oral hygiene of service users who require assistance with such matters. Service users are assessed regarding the risk of obtaining pressure sores; with appropriate preventative equipment provided as required. The incidence of any pressure sores are recorded and reviewed. All service users are registered with a GP. The home will refer to the District Nurse / Psychiatric Nurse for support and advice as required through the GP practice. Dental and chiropody services are provided Medication storage and processes were inspected. Medication is now correctly stored in a new ‘treatment room’. Records were properly maintained. Medication is supplied from the local surgery and it has now been agreed that in the very near future drugs will be packaged via the Monitored Dosage System. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 11 Staff were observed to treat service users with dignity and respect. Those service users spoken with confirmed this. One service user stated how much better the home was since the manager had been in post. This particular person has been in three other nursing homes and believes St. Margaret’s is the best. Based on discussion with the manager, the inspector considers that the care of service users toward the end of their lives would be appropriate and conducted with sensitivity and respect. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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, and 15 The routines of daily living and activities made available are flexible and varied. Service users receive visitors at any reasonable time throughout the day Service users are helped to exercise choice and control over their lives within the bounds of their individual capabilities Dietary needs are met. EVIDENCE: The inspector spoke, in some depth with five service users. They expressed that they felt they were able to exercise control over their lives by partaking in interests, hobbies and activities of their choice. They also appreciated the limits of their expectations based on their individual capabilities. They stated that staff helped to support and assist them. A daily record is kept, in respect of each service user, which when analysed will present a picture of that persons life style and interests within the home. A care assistant is now responsible for co-ordinating activities. The visitors book indicated that family and friends visit frequently at will. The inspector was able to speak with the son of a service user. He was happy with the care provided by the home. Lunch was observed to be a sociable occasion with the majority of service users eating in the dining room. The menus indicated that service users receive a varied and appealing diet. Specialist diets are catered for. Food is St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 13 now prepared in a new kitchen separate from the main building and situated in the car park. Heated trolleys are used to transport food to the dining room. The cook expressed satisfaction with the current arrangements. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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, 17, and 18 The complaints procedure is well publicised and would be used when required. The registered manager has a sound knowledge of all forms of abuse and is familiar with Adult Protection Procedures. Training for staff needs to be implemented. EVIDENCE: The home has a complaints policy that meets all the requirements of Regulation 22. A complaints log is available to ensure that a record of all complaints is recorded and kept. Details of the complaints policy are available in the statement of purpose and a full copy included within the service users guide The home has a policy in relation to adult protection, which includes information on whistle blowing. The manager has tried, on two occasions, to access training courses for staff without success owing to over subscription of these courses. It is important that staff do attend appropriate training. In the mean time it is suggested that management ensure that staff are familiar with and understand the relevant policies and procedures relating to Abuse. Several service users exercised their right to vote at the recent elections. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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, 23 and 26 The location and layout of the home is suitable for it’s stated purpose and provides a safe environment. The home was clean, hygienic and free from offensive odours providing a homely place to live Bedrooms are comfortable and contain the personal possessions of the occupant EVIDENCE: The home has been undergoing redevelopment which is now almost complete. This represents an improvement to facilities and living conditions for service users. Service users now have better access to all communal areas of the home. The entrance to the home is much improved. Bedrooms vary in size but are considered suitable for purpose. Many displayed the personal affects of the occupant and service users expressed satisfaction with their rooms. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 16 The home has an Infection Control policy. The home appeared generally clean. The home was generally free of offensive odours. The home employs separate cleaning staff. Adequate hand washing facilities are provided. The home has a sluicing facility. Separate laundry staff are employed. Suitable washing / drying machines are provided. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 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, 29 and 30 Robust recruitment policies and procedures are implemented. All staff are supported and receive induction training. A positive number of staff are on duty to meet the service user’s needs. EVIDENCE: The home has a duty rota that accurately reflected the number and skill mix of staff on duty during the inspection. Additional staff are on duty at busier times of the day. Currently at night there is one trained nurse and 2 carers on duty. Evidence that 44 of the staff team have now achieved NVQ level 2 was presented at the inspection. Several other staff are now enrolled on NVQ training so the target of 50 may well be reached by the end of the year.. The home’s employment policies and procedures are implemented. 2 written references were evidenced within a random selection of staff files. CRB checks and POVA checks are completed. Staff training, induction and development programmes are undertaken. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 18 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, 35, 36 and 38 The Registered Providers of St. Margaret’s have improved the overall service provided to include quality of care and lifestyle for the service users in promoting their health, safety and welfare EVIDENCE: The Registered Manager has now been in post for 7 months. During that time many improvements are noted not least the fact that of the 10 statutory requirements listed at the last inspection, only 2 require further attention. The manager is an RGN. With at least 20 years of experience. She is currently undertaking the Registered Managers Award. The inspector discussed the financial accounting procedures within the home and viewed appropriate policy documents. Based on this and the fact that nearly all service users manage their own finances it is considered that financial practices are sound. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 19 Employment policies and procedures were seen as appropriate. In house training and induction is also appropriate and the inspector noted that several staff have now undertaken short courses to include moving and handling. Supervision does occur in the home. This takes the form of staff being supervised by their seniors and advised accordingly of progress and competencies. This process of staff development is to be commended. It does not however fall within the meaning of supervision as referred to in the National Minimum Standards and as referred to in the last report. The inspector is, following discussion with the manager, assured that formal supervision will now occur at approximately 2 monthly intervals and be duly recorded. St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 20 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 x 3 x 3 N/A 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 3 COMPLAINTS AND PROTECTION 3 3 x x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x x x 3 2 x 3 St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 21 yes 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 OP18 Regulation 13.6 Requirement Timescale for action 30th. August 2005 2. OP36 18 (2) The Registered Provider must ensure that all staff receive training with regard to Adult Protection Procedures The Registered Provider must Immediate ensure that care staff receive formal supervision (as detailed in 36.3) at least six times per year 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 St Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Margarets D52-D04 S9258 St Margarets V216829 100505 Stage 4.doc Version 1.30 Page 23 - 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. 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