CARE HOMES FOR OLDER PEOPLE
St Margaret`s 25-27 Queens Road Harrogate North Yorkshire HG2 0HA Lead Inspector
Key Unannounced Inspection 18th July 2006 09:15 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 Margaret`s DS0000007791.V304565.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 Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Margaret`s Address 25-27 Queens Road Harrogate North Yorkshire HG2 0HA 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) 01423 529544 01423 875151 info@stmargarets.biz Mr John Kneller Mrs Wendy Margarita Kneller Mrs Ann Elizabeth Hayton Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to include up to 25 (OP) and up to 25 (DE (E)) up to a maximum of 25 Service Users. 6th December 2005 Date of last inspection Brief Description of the Service: St. Margarets provides a care service to 25 people with dementia who are over 65 years of age .The home is situated in a residential area of Harrogate with good access to the towns services and amenities. At the time of this visit the weekly charge ranges from £340 to £430.Not included in this charge is hairdressing, chiropody, papers and taxis. The service users guide tells service users /representatives that they can see the Commission for Social Care inspection reports about the home. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the home’s file. • Information submitted by the registered provider in the Pre Inspection Questionnaire. • An unannounced visit to the home which lasted eight hours and included a tour of the premises, talking to service users, care staff and management. Examining some records and observing staff working with service users. What the service does well: What has improved since the last inspection?
There has been some redecoration and refurbishment. A few bedrooms have been painted, some lounge chairs have been replaced and a new hall carpet fitted. This has improved the living space for service users. Hot water is monitored to reduce the risk of scalding. Risk assessments have been introduced. This reduces the risk of accidents and makes sure that risky activities are properly considered. Before staff start work, a specific criminal records reference is sought to make sure that the applicant is not barred from working with vulnerable adults.
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 6 What they could do better:
The information provided to prospective service users, their families and other representatives must be up to date and accurate in order to be sure that they can make an informed decision about moving into the home. The home is not being managed in a way that ensures that the needs of service users are properly identified and planned for. Admissions to the home must only take place when a full needs assessment has been undertaken and the home can confirm that they can meet the needs of the individual through the service they deliver. Management should consider discussing the application with other staff where all information is shared, views, opinions, and comments are listened to and fully debated before agreement is given for the admission. This ensures the best possible results for people being admitted to the home. Each service user must have a care plan that has been agreed with them or their representative. It should be written in plain English, be easy to understand and consider all areas of the individual’s life including health, personal, cultural and social care needs. The plan must include the support that staff have to provide to meet the needs of service users whilst maintaining their ability to retain some independence. Areas should be identified where staff are willing to support residents to take some risks in order for them to live interesting and fulfilling lives. Staff need to be provided with the skills and ability to support and encourage service users to be involved in the ongoing development of their plan and make the process interesting and worthwhile. A key worker system would help this process allowing staff to build up special relationships with service users and work on a one to one basis with them. Plans must be properly reviewed and where needs have changed, action taken and the plan amended accordingly. Good care planning means that service users receive a service that is specifically designed to meet their diverse care needs. The manager must engage the help of other professionals when managing some aspects of service users health needs. Involvement of health care professionals means that service users wellbeing is promoted. The management of continence needs to be more discreet to ensure the privacy and dignity of service users. Sufficient staff resources must be made available to allow for activities and stimulation. The key worker system would enable closer service user staff relationships where likes, dislikes and needs are shared. Key workers can then plan the activities that service users enjoy. The home needs to develop a system for displaying information and bringing attention about community events. When service users have particular interests, every effort should be made to help the service user maintain their interest and keep up any community involvement. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 7 The profile of the complaints procedure needs to be raised and management understand its importance in improving the service. Complaints need to be properly recorded in a manner that informs management that issues are followed up speedily and that the information is used in a constructive manner to improve service delivery. The homeowners must carry out the work that the fire authority has recommended to ensure the safety of service users in the event of fire. Accordingly, all of the work required by the health and safety officer must be done without delay to ensure the general safety of service users and staff. Improvements to the environment must be made. Where service users share a bedroom, screening must be provided in order to respect people right to privacy and dignity. The upgrading of bathrooms must make sure that three bathrooms have assisted bathing facilities to allow service users choice. The arrangements for smoking within the building must be managed in a manner that protects people from the effects of smoke that drifts into areas that service users have to pass through and sit in. Improvements need to be made in getting staff to complete NVQ training so that a minimum of 50 of care staff have an NVQ level 2 or equivalent. Higher numbers of care staff achieving NVQ level 2 or above means more staff on each shift have received the training relevant to the work that they do. This ensures that service users receive a service from a better-informed staff team whose practice is up to date. Management and staff need to be aware of equality and diversity issues to ensure that staff are able to translate understanding into positive results for service users in the areas of race, ethnicity, age, sexuality, gender, disability and belief. The manager needs to access specific training relating to delivering a service to people with dementia care needs. This will enable her to inform the homeowner of particular environmental needs that this group of people have and lead the staff team more effectively. Recruitment procedures must make sure that the homeowners seek all references. This minimises the risk of unsuitable staff being employed. The homeowners and manager need to look at imaginative ways that service users, staff and any other interested parties can be involved in the running of the home. This promotes an open and inclusive management style and allows service users and staff some ownership about the service delivered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 8 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 Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 9 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 and 3. Standard 6 does not apply to this service, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The lack of a personalised needs assessment means that the diverse needs of service users are not identified and planned for before admission. EVIDENCE: The manager gives a copy of the Service User Guide to the relatives / representatives of each prospective service user. The Guide informs people about the service that the home provides and what they can reasonably expect if they decide to move in. Included in this information are all the aspects of a person’s life that the staff will consider in order to promote the service user’s well being. Case tracking confirmed that this is not the case. All four of the service user files examined showed incomplete assessments prior to admission. The information gathered does not give a true reflection of all of the needs of the prospective service users. At the last inspection, a recommendation was made that there should be more detail included in the initial assessment. This has
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 10 not been achieved. The information collected is poor and is mostly ticks in boxes with very little or no additional information. Service users spoken to were unable to recall any of the circumstances surrounding their admission to the home. None of them had visited the home prior to admission but family, friends or care managers on their behalf had made visits. Two of the files examined did not contain contracts. They contained the local authority placement agreement which Mr Kneller the owner of the home says he uses as the contract. The remaining two files contained contracts but the fees payable had not been entered. Later in the day Mr Kneller recalled that the two files with contracts missing was due to the fact that he had sent them out to families for signing and they had not been returned. There was no evidence to support this. Four care staff were spoken to and were able to describe the admission procedure and the importance of making sure that the new service users felt welcome. They confirmed that they are given verbal information relating to the personal care support needed when a new service user is admitted. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The lack of a detailed and comprehensive care plan means that a service tailored to meet the diverse health and personal care needs of service users cannot be provided. EVIDENCE: Because the initial assessment is poor, care plans fail to address the diverse needs of service users. Case tracking confirmed the planning in place referred mostly to the physical needs of people using the service The social, religious and cultural needs were not identified. Incomplete plans run the risk of service users having a range of unmet needs. Service users or an advocate have not signed the plans suggesting that they have not been involved. The manager said she writes the plan then asks the service user/representative if it is all right. This is not an acceptable way of developing care plans. Plans do not consistently detail the action, which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. As required following the last inspection there was evidence that some risk assessments are completed.
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 12 One file examined showed that some of the behaviours of one service user could significantly impact on the wellbeing of others and on one occasion could have caused injury to another service user. There was no evidence that any help or guidance had been sought from health care professionals in order to review the situation and provide guidance for staff. The care plan for this service user identifies mental health issues but fails to instruct staff on how to deliver the service when difficult situations arise. A monthly review of the plan takes place, which is meant to ensure that any changes to service users physical needs are identified and acted upon. In the case of one service user case tracked, there was evidence of a recent foot injury that had compromised her mobility. There had been no review of the plan in order to safely manage this situation. This service user was observed trying to walk with nothing on her feet and using a “bed table” as a walking aid. Incontinence pads were seen on some chairs. This practice immediately identifies people who are incontinent and is therefore considered poor practice in the management of continence. It demonstrates a lack of respect for the privacy and dignity of service users and disregards the need to provide a discreet service. Service users spoken to, because of their cognitive impairment, were unaware that they have a care plan and don’t recall being involved in its development. Discussions with staff found that they are aware of the plan but are not involved in the development of it with the service user. Some of the service users spoken to indicated that they were happy with the service provided. One service user commented that she was “quite happy and comfortable” and that the staff were helpful. Staff are however meeting some of the needs of service users despite a lack of clear plans and guidance. Service users looked clean and cared for and staff were involving them in recreational activities. Staff complete a daily record for each service user and inform management of any changes to service users needs. Staff were observed providing support in a kind and helpful manner. They were able to give examples of best practice relating to the promotion of respect for the privacy and dignity of service users. Feedback from the four relatives surveys returned show that they are satisfied with the overall care provided. Comments received included “I cannot speak too highly of the standard of care” One service user survey returned confirmed that the service meets their personal and health care needs. Service users are registered with a General Practitioner and have access to the primary health care team. Staff arrange appointments. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 13 Medicines are stored and administered safely. No one takes care of their own tablets and there was no evidence to suggest that service users are given this option subject to a proper risk assessment. Service users are at risk of not receiving a service that is tailored to meet their entire individual needs St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Service users benefit from flexible routines but the lack of a service specifically designed to meet individuals social, cultural and recreational needs has the potential to impede wellbeing. EVIDENCE: Case tracking confirmed that the social, cultural and recreational interests and needs of service users are not identified. Without this information it is unlikely that these particular needs of service users are met. The manager explained that a member of staff is identified on the rota each day and is responsible for arranging in-house activities. Staff were observed engaging service users in games. The manager was unable to provide a programme of activities saying that the staff decide the activity day to day. This way of arranging activities ignores the need to consult with service users or their relatives about the type of activities that might interest individuals. There was no evidence of any consultation that would enable service users to enjoy a full and stimulating lifestyle with a variety of options to choose from. Visitors are encouraged and made welcome. Relative feed back confirmed that they are made to feel welcome in the home and are in general able to see
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 15 their relative in private. One relative commented that she was unable to have a private visit because the service user shared a room. Discussions with service users showed that routines are flexible and that service users retain control in some areas of their lives. Staff spoken to were able to give examples about how they support service users in a manner that respects their choices and wishes in some areas of their life. Meals are taken in an attractive dining room. Tables are set with cutlery and a cold drink. Condiments were not available. A hot drink was provided in the lounge after the meal. There is a choice of food at each mealtime and service users food preferences are known about. A number of people remained in the lounge for their lunch. It was difficult to assess if this was the preferred wish of the service user or because of the mobility difficulties/eating difficulties of some people the decision has been taken that they remain in the lounge. Conflicting explanations were given. There was no evidence recorded in the care plan of any discussions that had given careful consideration to this course of action. Mealtimes should be considered as a social occasion and to exclude a number of people because of their disability does them a disservice. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The lack of a robust means of following through complaints has the potential to leave service users with unresolved issues, which could have a detrimental effect on their wellbeing. EVIDENCE: Information contained in the service users guide and given to service users or their representatives indicates that the home’s complaint procedure is in line with best practice. There is no evidence of this. There is no record of complaints that shows the action that management take to arrange a speedy resolution in the best interest of the parties concerned. Because of the cognitive impairment and dementia care needs of all of the people using the service, it is unlikely that they are able to make their own complaints and have to rely on others to perform this task for them. It is therefore vital that management capture this information in a way that they can be confident that any concerns or complaints raised are listened to and dealt with properly. The manager says that complaints are usually recorded on service users daily record sheets. This method of recording allows information to get “lost” and works against showing that the management has learnt from the process and is endeavouring to make sure that the same issues don’t happen again. There is no analysis of complaints as part of the quality monitoring system. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 17 Staff spoken to knew to immediately report to the manager if they knew or suspected that a service user was being harmed. Staff receive training in “elder abuse”. The management operates a system that protects service users from financial abuse in circumstances where service users money is held for safekeeping. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Service users live in a clean, comfortable home. The lack of some facilities restricts service users choices. The poor arrangements for smokers makes for an unpleasant and unhealthy situation for people living in the home. EVIDENCE: The home has a friendly atmosphere and is clean. The two lounges are spacious and overlook well kept front gardens with seating areas. There has been some recent refurbishment and redecoration to improve the living space. The premises are arranged over three floors with few considerations given to environmental issues that help people who have cognitive impairment or dementia care needs. Bedrooms have basic furnishings and service users are invited to bring in their own items. Three bedrooms have ensuite facilities. Of the five shared rooms, only one has screening to allow service users any privacy.
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 19 There are four bathrooms but only one can be used. The remaining three lack any means of assistance and are therefore not suitable for the needs of the people using the service. One of the bathrooms contains a sluice rendering it unsuitable for use by service users. This lack of sufficient usable bathing facilities must cause restrictions on when and where service users can bathe. There are notices pinned up around the home and in one instance in a service users en-suite instructing staff about their duties. This institutional practice is a poor management strategy for the proper support and guidance of staff. It is also not conducive with promoting a relaxed comfortable environment for service users. Access to a call bell had been removed in one toilet. An area has been designated for smoking. It is beside the dining room and has no proper ventilation. Consequently when people exit the smoking room the smoke drifts into the hallway and dining room. This is most unpleasant and has health implications for service users and staff. Mr Kneller was asked at the last inspection to arrange venting to the outside. This has not been done. There are a number of fire and health and safety issues that have not been addressed. These are described in detail later in the report. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. There are sufficient numbers of staff to respond to the needs of service users. Poor recruitment practices place service users at risk. EVIDENCE: Staff were observed responding appropriately to service users and spent time talking to them in order to understand their wishes. One service user spoken to said staff “were all very kind.” The rota showed that there is enough care staff on each shift taking into account times of peak activity. Staff spoken to said that they had enough time to deliver the service. Comments received from relatives show that in their opinion there are always sufficient numbers of staff on duty. Staff files examined showed shortfalls in the recruitment process. The homeowner had relied on references provided by one applicant and had not sought his own. This is poor practice and has the potential to recruit unsuitable people thereby placing service users at risk. There is an induction programme that ensures new staff members are given the right information to be able to do their jobs. Staff spoken to said that the on going training programme provides them with the skills and knowledge to meet service users needs. The training programme includes the mandatory training needed to meet service users basic needs such as First Aid, moving and handling and food hygiene. Specialist training provided includes dementia
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 21 care and abuse awareness. Consideration should be given to providing training in continence and infection control. This will further improve staff’s knowledge in the best interests of service users. 40 of the care staff have achieved National Vocational Qualification level 2. In order to ensure a workforce whose practice is up to date and in line with current best practice, this percentage needs to improve to 50 . St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The lack of proactive management and good quality monitoring schemes prevents the type of service delivery that service users have the right to expect. EVIDENCE: The manager has achieved a recognisable qualification for managing a care home. She has not undertaken any training relating to some specific aspects of managing a care service for people with dementia care needs. Staff and service users say the manager is easy to talk to and approachable. The manager has started to develop a quality assurance scheme. An annual survey of relatives is about to start and this will be extended to others who have an interest in the service. It is anticipated that the findings from the surveys will be analysed and inform the planning for next year. In order to ensure on going improvements for service users, management must introduce
St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 23 a continuous self-monitoring system and an internal audit that takes place annually. There are a number of fire safety issues that the local fire authority made recommendations about in November 2004 and again in April 2006. Mr Kneller has not made arrangements to have the work done. This means that service users safety is compromised in the event of a fire. A recent visit made by a local authority health and safety officer outlined again a number of previously identified issues relating to the safety of service users and staff. The work has not been done. An order has been issued and Mr Kneller said he intends to comply with the legal requirements made within the timescales specified in the report. Hot water temperatures are monitored to minimise the risk of scalding. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 24 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 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5(1)(b) Requirement Timescale for action 30/08/06 2. OP4 12 and14 3. OP7 15 Information in the service user guide given to service users must include the terms and conditions in respect of accommodation including the amount and method of payment of fees. Prospective service users must be advised and have accurate information about the service they can expect for the fee that is paid. All of the needs of a service user 18/08/06 must be assessed before admission is arranged. The registered person must confirm in writing to the service user that after considering the assessment, the care home is capable of delivering a service that meets their needs. The needs assessment must be kept under review and revised as and when changing needs dictate. A written care plan that includes 30/08/06 all of the service users needs must be provided. The plan must include clear guidance to staff about the support that they have to provide to meet service users needs. Consultation wherever
DS0000007791.V304565.R01.S.doc Version 5.2 St Margaret`s Page 26 4 OP8 12 (1) and 13(b) 12(4) 5 OP10 6 OP12 16(2) (m) and (n) 7 OP16 22 17(2) schedule 4 (11) 8 OP19 13(4) and 23(2)(p) 9 10 OP21 OP29 23(2)(j) 19 (4)(b) possible should take place with the service user or their representative. The plan must be kept under review and service users or their representative made aware of any revisions. The registered manager must when necessary access treatment and advice from other health care professionals. The registered person must make suitable arrangements to ensure that the home is conducted in a manner which respects the privacy and dignity of service users. Incontinence pads must be removed from the lounge chairs and where service users share a room, screening must be provided. The registered manager must consult service users/representatives about the programme of activities arranged by the home. Taking into account the needs of service users, activities in relation to recreation, fitness and training must be provided. The registered manager must follow the home’s complaint procedure. Following a complaint, an investigation must take place and the complainant informed of the outcome / any action to be taken. The ventilation of the smoking room must be improved. The area must be vented to the outside to stop smoke drifting into the corridor and dining room. The registered person must provide a minimum of three assisted bathing facilities The registered provider must seek their own references and not rely on references provided
DS0000007791.V304565.R01.S.doc 18/07/06 31/07/06 31/08/06 18/07/06 31/08/06 31/10/06 18/07/06 St Margaret`s Version 5.2 Page 27 11 OP31 10 (3) 12 OP33 24 13 OP38 23 (4) 14 OP38 13 (4) by the applicant. The manager must undertake training that will inform her about the management of a service that provides care for people with dementia care needs. The registered providers and manager must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided. The registered providers must complete all the fire safety work recommended by the fire authority’s April 06 report The registered providers must comply with the legal requirements in relation to health and safety as detailed in the recent order served by the local authority environmental health department. 31/10/06 31/10/06 31/08/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP7 OP28 Good Practice Recommendations Staff should be involved with working with the service user to develop the care plan. Consideration should be given to introducing a key worker scheme. The registered person needs to provide evidence that an additional 10 of staff are registered to start their NVQ level 2 award. Infection control training should be provided. St Margaret`s DS0000007791.V304565.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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