Inspection on 11/07/06 for St Margaret`s

This inspection was carried out on 11th July 2006.

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 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 20/10/05

St Margaret`s 10/05/05

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 Cornwall TR9 6LX Lead Inspector Alan Pitts Key unannounced Inspection 11th July 2006 09:30 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 St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margarets Address Mylord Road Fraddon St Columb Cornwall TR9 6LX 01726 861497 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) saintmargarets@tiscalli.co.uk Blakeshields Limited Mr Christopher Lydon Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability (5), Terminally ill (5) of places St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of service users not to exceed a maximum of 28 Date of last inspection 20th October 2005 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 DS0000009258.V297917.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 11th July 2006 over a period of approximately 5 hours, commencing at 9am. The inspector met with the nurse in charge, staff on duty, 4 service users, and a visiting relative. The inspector toured the premises, which was seen to be clean and pleasantly decorated throughout. Various records, policies and procedures were inspected and found to be satisfactory, any exceptions are specified in this report. 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 generally satisfied with the services offered. What the service does well: What has improved since the last inspection? 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. Staff are receiving frequent and regular supervision. Ongoing training is available to staff. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 6 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 DS0000009258.V297917.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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 the following standard(s): 1, 3, 6 Service users are provided with the information they need. The home does not adhere to accepting admissions on the basis of a full care needs assessment. Standard 6 is not applicable, as the 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. The most recent admission to the home arrived the day before the inspection. Information relating to this individual’s care needs arrived by fax at the time of the inspection. The registered manager must ensure that new service users are only admitted on the basis of a full care needs assessment. Standard 6 is not applicable, as the home does not provide intermediate care. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 9 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): 7, 8, 9, 10 The health care needs of service users are identified, planned for and met. The medication procedure needs reviewing and amending, but medicines are stored and administered safely. Service users said that they are treated with dignity and respect. EVIDENCE: The care plans contain all the relevant information required, and show regular and frequent review by a nurse, but there is little indication of service user involvement in this. In respect of health care the daily entries are informative. The registered manager should do more to ensure the involvement of the service user, or their representative, in reviewing care plans. The care documentation includes a comprehensive set of risk-assessments (e.g. bed rails), and a ‘pen portrait’ of the service user, but those examples seen at the time of the inspection were incomplete and had not been signed by the service user, or their representative. The registered manager should ensure that all forms used are completed fully and the relevant signatures obtained. 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 St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 10 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, optical, and chiropody services are provided. Medicines were seen to be appropriately stored and administered. Medicine Administration Records were seen to be in order, though where instructions are hand written the registered manager should ensure that there are two staff initials confirming that the instructions have been checked as correct. The medication policy in use does not detail the process for ordering, receipt, and return of medications. The registered manager should review and amend the medication procedure to include the ordering, receipt, and return of medication. The care documentation shows that there is liaison and referral to other healthcare agencies as appropriate. Medical appointments are recorded in the diary. Staff were observed to treat service users with dignity and respect. Reference to the service user’s privacy and dignity is made in all care plans. Those service users spoken with confirmed that they felt that they were treated appropriately and with due deference. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 11 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, 15 Service users said that there was a lack of activities, insufficient to maintain their recreational interests. 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: A care assistant is now responsible for co-ordinating activities, but according to the relevant activities record there was: 1 activity in May; 2 activities in April, and; 1 activity in March. The service users spoken with said that there was “not much in the way of activities”. The daily entries in the care documentation make sporadic reference to how service users spent their day, but more usually states where they spent their day. The entries are repetitive and do not demonstrate the options available, or offered. The registered manager must do more to ensure that there is a range of social/recreational activities available, which reflects the interests of the service users (as recorded in the ‘pen portraits’), and ensure that these activities are recorded. The visitor’s book indicated that family and friends visit frequently, and service users confirmed this. The visitor’s book is a loose-leaf folder, and the inspector noted that multiple pages were in use at the time of the inspection. The St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 12 registered manager should consider a bound book for this purpose. The inspector was able to speak with the niece of a service user, who was happy with the care provided by the home. The service users also confirmed that they would feel able to express their views and/or concerns, and they felt that choice was available to them. 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 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. Service users were complimentary about the food, and all confirmed that they would be able to have an alternative meal if they so wished. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 13 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): 16, 18 Comments from service users were positive, but the home must develop its Protection Of Vulnerable Adults procedure. EVIDENCE: A complaints procedure is in place, and the service users spoken with confirmed that they would feel able to express any concerns that they may have. A visitor also confirmed this. The registered manager should review and amend the home’s complaints procedure to include the contact information for the local Adult Social Care Office. The home’s Protection Of Vulnerable Adults procedure was not evident in the policies and procedures manual, and the nurse in charge was not aware of where this document was. The inspector spoke with a service user who had recently made known her concern over one member of staff, and this was recorded in the daily entries, but there was no indication of the action taken subsequently. The inspector is not concerned about the individual incident as the service user did not express any concern, but there was no evidence of the relevant procedure being implemented. This was discussed with the registered provider at the time of the inspection. The registered manager must develop a protection of vulnerable adults procedure, which refers to Cornwall Adult Services procedures, ‘whistle blowing’ and the ‘No Secrets’ guidance, and provides ‘plain English’ instruction as to the steps to take in the event of an allegation of abuse, including relevant contact details. The registered manager must ensure that all staff are aware of the home’s Protection Of Vulnerable St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 14 Adults procedure, and are appropriately trained to protect service users from abuse. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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 the following standard(s): 19, 26 The location and layout of the home is suitable for it’s stated purpose and provides a safe environment. The home was clean, and free from offensive odours providing a homely place to live. Bedrooms were comfortable and contained the personal possessions of the occupant. EVIDENCE: The home offers accommodation for 28 service users. There are 13 en-suite rooms with their own lavatory facilities. There are sufficient communal lavatory and bathing facilities throughout the home. There is a range of care/nursing aids provided at the home. Access between floors is aided by a passenger lift. Service user rooms were seen to be clean, comfortably furnished and personalised to varying degrees. The home employs a handyman, and the premises were seen to be wellmaintained. There are two sluice facilities. The Registered Provider should provide proper rack storage in the sluice rooms. The sluice rooms do not have St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 16 a hand washing facility. The Registered Provider should audit the premises to ensure the provision of staff hand washing facilities in sluices and communal lavatories and bathrooms. The nurse in charge advised the inspector that the staff had been provided with individual alcohol solution bottles, but these were not evident in use. Larger bottles of alcohol solution were seen in corridors. The laundry is generally suitable and capable of meeting the demands of the home, but the two washing machines are top-loaders and do not have a sluice facility. This means that the machines cannot properly sluice fouled linen, and when staff have to deal with fouled linen they have to open the red sacks used in order to get the laundry into the washing machine, which defeats the purpose of the red dissolving sacks. In the interests of infection control the Registered Provider should replace the washing machines with front-loading, industrial-type machines that have a sluice cycle facility. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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 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, 30 A sufficient number of staff is on duty to meet the service user’s needs. There is evidence of ongoing staff training, and a robust employment procedure. EVIDENCE: The home has a duty rota that accurately reflected the number and skill mix of staff on duty during the inspection. At the time of the inspection there was one nurse and four care staff on duty, supported by other ancillary staff. Additional staff are on duty at busier times of the day. At night there is one trained nurse and 2 carers on duty. Service users, and a visitor, were complimentary about the care provided. There is an active NVQ programme, though the actual percentage of staff qualified to NVQ was not ascertained at this time. Three staff spoken with confirmed that they had access to training recently, including: palliative care, fire training, 1st Aid, No Secrets, and manual handling. The home’s employment policies and procedures are implemented as a rule, though one staff file, of two inspected, (recently appointed) showed only one reference being received to date. CRB checks and POVA checks are completed. There has not been a new member of care staff appointed since the last inspection. The registered manager is aware of the need to use a National Training Organisation induction programme for all new care staff. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 18 St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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 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, 33, 35, 36, 38 The registered manager has improved the overall service provided for the service users in promoting their health, safety and welfare. More could be done to ensure the home is run in the best interests of service users with better provision for social/recreational needs. Service user financial interests are safeguarded. EVIDENCE: Service user comments were positive, and the registered manager has improved the ethos and leadership to the benefit of the service user’s best interests. Service users said that the staff were attentive and caring, and the inspector observed staff attending to service user needs in an appropriate and respectful manner. The service users, and a visitor, confirmed that they are able to make meaningful choices in respect of their lives at St Margarets. There is effective staff supervision at regular and frequent intervals. The nurse in St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 20 charge was not aware of where the home’s procedure folder was. There is a procedure folder held in the upstairs office, the contents of which are not dated. As mentioned previously, specifically referring to the home’s Protection Of Vulnerable Adults procedure, the registered manager should review and amend all the home’s policies and procedures to ensure that all relevant areas are covered and reflect current good practice. The registered manager should ensure that the home’s policies and procedures are readily available to staff at all times. The inspector discussed the financial accounting procedures within the home and viewed appropriate records, which are supported by receipts and stored securely. All but three service users look after their own financial interests, or have a representative doing so. The Health and Safety poster displayed in the entrance to the home needs to be completed where information is asked for. There is evidence of ongoing staff training in health and safety relevant topics (e.g. Fire, 1st Aid, moving and handling). An Environmental Health Officer inspection in January 2006 noted that there were “good, robust systems in place”. Appropriate insurance is held by the home. Records show that there is regular maintenance and safety checks carried out on the premises and the facilities within, including electrical and fire systems, and gas safety checks. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 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 X 2 X 3 3 X 2 St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 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 OP3 Regulation 14 Requirement Timescale for action 17/07/06 2. OP12 16 3. OP18 13.6 The registered manager must ensure that new service users are only admitted on the basis of a full care needs assessment. The registered manager must do 01/09/06 more to ensure that there is a range of social/recreational activities available, which reflects the interests of the service users (as recorded in the ‘pen portraits’), and ensure that these activities are recorded. The registered manager must 01/08/06 develop a protection of vulnerable adults procedure, which refers to Cornwall Adult Services procedures, ‘whistle blowing’ and the ‘No Secrets’ guidance, and provides ‘plain English’ instruction as to the steps to take in the event of an allegation of abuse, including relevant contact details. The registered manager must ensure that all staff are aware of the home’s Protection Of Vulnerable Adults procedure, and are appropriately trained to protect service users from abuse. DS0000009258.V297917.R01.S.doc Version 5.2 St Margarets Page 23 This requirement has been carried over from the previous inspection. 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 OP7 Good Practice Recommendations The registered manager should do more to ensure the involvement of the service user, or their representative, in reviewing care plans. The registered manager should ensure that all forms used are completed fully and the relevant signatures obtained. Where instructions are hand written on Medicine Administration Records the registered manager should ensure that there are two staff initials confirming that the instructions have been checked as correct. The registered manager should review and amend the medication procedure to include the ordering, receipt, and return of medication. The visitor’s book is a loose-leaf folder, and the inspector noted that multiple pages were in use at the time of the inspection. The registered manager should consider a bound book for this purpose. The registered manager should review and amend the home’s complaints procedure to include the contact information for the local Adult Social Care Office. The Registered Provider should provide proper rack storage in the sluice rooms. The Registered Provider should audit the premises to ensure the provision of staff hand washing facilities in sluices and communal lavatories and bathrooms. In the interests of infection control the Registered Provider should replace the washing machines with front-loading, industrial-type machines that have a sluice cycle facility. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 24 2. OP9 3. OP13 4. 5. OP16 OP26 6. OP33 7. OP38 The registered manager should review and amend all the home’s policies and procedures to ensure that all relevant areas are covered and reflect current good practice. The registered manager should ensure that the home’s policies and procedures are readily available to staff at all times. The Health and Safety poster displayed in the entrance to the home needs to be completed where information is asked for. St Margarets DS0000009258.V297917.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 DS0000009258.V297917.R01.S.doc Version 5.2 Page 26 - 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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