Inspection on 20/11/07 for St Margaret`s

This inspection was carried out on 20th November 2007.

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 23/11/06

St Margaret`s 18/07/06

St Margaret`s 06/12/05

St Margaret`s 17/05/05

St Margaret`s 05/10/04

St Margaret`s 10/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Margaret`s 25-27 Queens Road Harrogate North Yorkshire HG2 0HA Lead Inspector Kate Shackleton Key Unannounced Inspection 20th November 2007 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 Margaret`s DS0000007791.V349901.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.V349901.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 Marie Whitelock in post but not yet registered. 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.V349901.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. 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. On the 20/11/07 the provider said that the weekly charge ranges from £359:50 to £446:73. Not included in this charge is hairdressing, chiropody, papers and taxis. The Service Users Guide tells service users /representatives about the service and the Commission for Social Care inspection report is displayed on the notice board in the home. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Tuesday the 20th November 2007. The visit was unannounced. Prior to the visit the provider completed an Annual Quality Assurance Assessment and surveys were obtained from people using the service, relatives, health professionals and some staff. It was decided to involve an expert by experience to accompany one inspector at this inspection. The expert by experience spent approximately three hours in the home talking with residents and staff regarding their views on nutrition and activities. She had lunch with residents. The inspector spent eight hours observing practices, discussing the progress of the service and how outcomes have improved since the last visit. A tour of the environment took place and records regarding care plans, risk assessments, medication, staff training and complaints and protection were all inspected. Aspects of health and safety and quality assurance were discussed. Outcomes for people who use the service have deteriorated since the home was last inspected in November 2006. This was evident in some poor care practices observed during the visit, risky medication procedures, the lack of comprehensive risk assessments and an environment that does not support people with dementia to be independent. However a qualified manager has recently taken up post and she is committed to improving the standard of service. What the service does well: What has improved since the last inspection? St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 6 The management of continence is done in a more discreet manner maintaining residents’ privacy and dignity. The implementation of quality monitoring systems and the production of a service improvement plan will help management to focus on what they need to do to improve service delivery. 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. The summary of this inspection report can be made available in other formats on request. St Margaret`s DS0000007791.V349901.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 Margaret`s DS0000007791.V349901.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Before admission to the home proper assessments are completed. This ensures that people are only admitted when the manager is confident that the service can deliver the care needed. EVIDENCE: Four resident files examined showed that proper assessments are completed prior to admission. For individuals referred by Social Services the manager obtains a summary of the Care Managers assessment. For individuals who are self - funding the manager or her deputy carry out a needs assessment, which looks in detail at all aspects of the persons’ life. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 9 Everybody who is referred receives a visit from a senior member of the homes staff so that proper discussions can take place to establish whether or not the service can meet the needs of the individual. This meeting allows people the opportunity to ask questions about living at St Margaret’s . The manager is aware of the importance of getting this assessment right in order to be sure that people are admitted only when she is confident that the service can deliver the care needed. The manager has devised a new pre admission assessment document to help this process. More information that the prospective resident may not be able to provide is gathered from relatives and other representatives. Before making a decision prospective residents and their representatives are offered the opportunity to spend time in the home including having a meal if they want to. An individual member of staff (Key worker) is allocated prior to admission. Their role is to take a special interest in the person and help them understand how the home is organised and run. This helps to ease the residents’ anxieties when they first move in helping them to settle into the life of the home. Resident’s and relatives surveys confirmed that people were given enough information about the home before they moved in which helped them to make a decision as to whether or not St Margaret’s would be the right place for them to live. Comments included “I had two meetings with the owners before my mother was transferred” St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Incomplete care planning and medication recording alongside poor care practices has the potential to place some residents wellbeing at risk. EVIDENCE: All the files examined contained a care plan. The manager is changing the document to make it easier to use. Plans set out some but not all of the actions which staff need to take to ensure that the health, personal and social care needs of the resident are met. One plan showed significant fluctuations in the residents’ weight. There was no nutritional risk assessment or nutritional care plan and daily recordings did not record this information. Another plan identified special dietary needs because of a medical condition but no nutritional risk assessment had been done. There St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 11 is no evidence that proper nutritional assessments are completed on admission. One file records information on the13/07/07 relating to a residents’ tendency to fall out of bed. There is no risk assessment or plan to manage this situation. The manager was not aware of this information held on the file. Most of the plans included a manual handling risk assessment with a moving and transferring care plan. None of the plans included a falls risk assessment. Plans are reviewed monthly and any changes to care needs are recorded. One of the two staff surveys received comments that information about changes to residents needs is not always written down or passed on when shifts change. A specific example was given. An anonymous complaint received recently by the commission gave examples of poor care practices. The complainant said that call bells were not accessible to residents when they are in their bedroom during the day and that residents are routinely got ready for bed from 5:30pm. During this visit the inspector entered a bedroom and found that the light bulb had blown, two people were sitting in semi darkness unable to call for assistance because the call bell was positioned too far away from them. The manager said that she would make better arrangements. She has already had a staff meeting to discuss with staff that residents should not be put into their nightclothes or taken to bed early unless they are indicating that this is their preferred wish. Residents’ preferences such as rising and retiring times and other preferences relating to their daily routines should be recorded in their care plans. Residents are registered with a GP and can access other health care professionals. Recordings seen on the files confirm this. The majority of surveys received from residents and relatives confirm that residents receive the care and support that they need and that their health needs are met. Comments included “responses to any requests are dealt with immediately” and “staff appear very caring.” Due to a medication error earlier this year an inspection by a CSCI pharmacist was completed. The report sent to the provider following this inspection identified that there were weaknesses in some areas of medication handling and recording. It was not clear from administration records whether medicines are always given. Medication storage arrangements were unsuitable and insufficiently secure. There had been a lack of supervision and staff St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 12 understanding of the safe handling of medication. This meant that people living in the home did not always receive their medication as prescribed and their health and wellbeing may be at risk of harm. The Pharmacy inspector made a number of requirements in order to improve the management of medication and ensure the safety and wellbeing of residents. The current manager who was not in post at the time of this inspection indicated that she was not aware of the inspection findings or the report. A number of improvements have been achieved relating to the secure storage of medicines and an improved policy and procedure has been implemented to guide staff practice. All staff who administer medicines have had further training. Medication records contain a photograph of the resident to aid identification. All of these measures seek to minimise the risk of medication errors. However examination of records continue to show gaps in recording indicating that medicines have not been offered. Unexplained gaps in the administration record may mean that inappropriate health decisions may be taken due to lack of accurate information. Proper codes are still not being used. The range of codes should be used fully to help identify whether, for example, a medication review is needed. Hand written entries made by staff on the Medication Administration Record are not signed, dated and witnessed. To help make sure there is an accurate record of medication changes the person amending the chart should sign and date their entry and a witness should countersign this. The administration of prescribed creams are routinely not recorded on the MAR chart meaning it is not possible to be sure these medicines are being used as prescribed. A member of staff was seen administering medicines in an unsafe manner placing residents at serious risk. It would seem that regular competencies of staff to administer medications is not carried out. Despite assurances given to the pharmacist that weekly medication checks would be done, this has not happened. The monthly quality audit was not up to date. No one currently living in the home manages their own medicines and no arrangements are available in the home to support someone who wished to do so. No specific risk assessment protocol and agreement process for selfadministration is in place. This suggests a lack of commitment to supporting anyone who may wish to self medicate. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 13 Some poor practice was observed relating to the privacy and dignity of residents. One resident was seen sitting in a wheelchair. Her clothing had not been arranged in a manner that preserved her dignity. Her bare legs were exposed up to her thighs. This was pointed out to a member of care staff who started a conversation in front of others about the difficulties of providing a service to this resident. This showed scant consideration to confidentiality and a lack of respect for the resident. Staff induction training covers topics relating to privacy and dignity and staff were observed knocking on bedroom doors before entering. In shared bedrooms screens are available and residents can have keys to lock their bedroom door. A requirement made at the last key inspection to manage incontinence in a more discreet manner has been achieved. Staff was observed providing support in a kind and helpful manner and service users looked clean and well cared for. We have judged the Health and Personal care outcome group as adequate on balance. Within this overall judgement some particular aspects of the service provided are poor. We have taken into account the commitment and capacity of the new manager to continue the early improvements already evident, in making our judgement. St Margaret`s DS0000007791.V349901.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some residents may receive a service that meets their needs, others will not. EVIDENCE: The pre admission assessment and the care plan records residents, leisure and recreational interests including their religious beliefs. Some Christian festivals are celebrated. A list of the week’s activities was displayed on the notice board, which indicated manicures on the day of this visit. The expert by experience found this to be popular with the ladies and one gentleman asked for a pedicure, which the carer said she would willingly do later, but in his own room. Chairexercises and crafts were listed for subsequent days. One member of staff recalled how the residents all enjoyed live music and singing which was provided by a visitor 2 or 3 times a year. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 15 Some residents were observed moving freely around the home. The majority were sitting about doing nothing in particular. Televisions were on in both lounges and residents were asked after lunch whether they would rather listen to the radio. It was difficult to judge if residents were really watching or interested in the programmes. During the afternoon some residents were having manicures. Most of the activities take place on weekday afternoons. Staff in general only interacted with residents when a task had to be completed. One relative survey comments “My family visits mum on a regular basis but have yet to see any of the activities that we were told are in place to stimulate the residents and alleviate their periods of boredom.” Feedback from other surveys confirmed that some activities that service users can take part in are arranged. The home will make arrangements for residents to either attend church or have clergy visit. The manager is devising individual activity records and has recently purchased some board games including reminiscence therapy. A designated member of staff is soon to be nominated as the activity organiser. There is an open visiting policy with no restrictions. Visitors are made welcome. At the time of this visit visitors were seen in the home. Residents can see their visitors in private either in their bedrooms or a “visitors room”. From information provided by the provider in the Annual Quality Assurance Assessment and observations made on the day, there was little evidence to show that the daily routines support people with dementia care needs and or other cognitive impairment to be involved in planning or having control over their day to day activities. It is not easy for them to find their own bedrooms on their own. There is no separate lounge where residents can get away from other people. There is no easily accessible secure garden, which is designed to include scents and possibly enable residents to grow plants and vegetables. Staff rarely take residents on activities outside of the home. There is a lack of meaningful individual activities. Residents with dementia should be provided with a range of activities that stimulates them e.g. music, art and opportunities to take part e.g. vegetable peeling, making cakes, helping in the garden, folding laundry, setting tables, arranging flowers. There was no evidence that key workers (Care staff) have these type of discussions with residents and record their findings so that a person centred approach is taken. One resident commented “ I’m quite happy here and I like my room, but I don’t know anywhere else to compare it with’. Several residents said they would really enjoy a trip out, if one was offered. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 16 Two residents who spent most of their time in their bedroom felt disadvantaged without a telephone to access friends, or a remote control to enable choice of programmes on their TV. A mobile phone would be appreciated (as used in their own home previously) The manager said she will arrange for this to be done. Lunch time was observed and a meal was taken with residents. The meal was liver with mashed potato, sweet corn and leeks. The expert by experience found that the liver had rather a strong flavour and was granular, and of the 4 residents at the table only one ate all of the first course, and asked for a second helping. There was a choice of 2 sweets and plenty of squash drinks offered. Residents were provided with discreet support if they needed help. Consideration should be given to enabling people who are able to the opportunity to independently serve themselves at the table e.g. water jugs/fruit drinks. There is no positive choice of meal offered. The main course is a set menu. An alternative is offered but this is not the same as been given a choice. Assurances were given by the staff that residents could ask for anything they wanted, have drinks at any time, and the staff were in tune with individual preferences. Best practice dictates that residents should be offered a choice of meal of equal value at each meal time. A healthy option should also be provided. For people with dementia the choice should be offered at the time the meal is served. This allows for discussion to explain what it is. Other people may be able to make the choice earlier in the day. One carer in the dining spoke throughout lunch with a raised voice, albeit a friendly manner, which made the dining experience a rather noisy affair. For people with dementia exposure to noisy environments can be difficult for them. Meals can be taken wherever the residents wants e.g. dining room, lounge or bedroom. Food and drinks are available outside set meal times. Special diets are catered for e.g. diabetic and vegan. Catering staff spoken to is aware of residents food preferences. The cook has not received training on catering for people with dementia. Responses from surveys about liking the meals provided were mixed. Three people always liked them, three usually did, one never did and three didn’t respond. One commented that her relative had gained weight since being at St Margaret’s. Another said, “that the food is served cold and not very appetising” further commenting on the small portion and poor quality of the food “broccoli was yellow” and “teatime was bread and a cheap cheesecake”. Dry food supplies and frozen food stored in the home were branded good quality makes. There was no evidence of cheap “budget” brands St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives feel able to complain without fear of repercussions. EVIDENCE: There is an easy to understand complaints procedure that is included in the Service users Guide. The guide is given to every service user or their representative. Discussions with staff confirmed that they understand the complaints procedure and that if they suspected or witnessed any abuse of residents they would report it to the manager. Staff receives training in this aspect of their work. Surveys received confirm that residents /representatives know who to complain to. Management say that they have received no complaints about the service. The Commission for Social Care has received one complaint. The providers were asked to investigate and take appropriate action. This was done in a satisfactory manner. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 18 The suspension and subsequent resignation of a member of staff for behaviour that could have put a resident at serious risk has not been referred in accordance with the Care Standards Act for consideration for inclusion on the Protection of Vulnerable Adults register. This course of action was discussed with the proprietor Mrs Kneller. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. To empower and enable service users a more dementia friendly environment needs to be created. EVIDENCE: The home has a friendly atmosphere and is fresh and clean. The two lounges are spacious and overlook well-kept front gardens with seating areas. The expert by experience found that the grounds around the care home were inaccessible to the residents the back garden being hazardous with steps and loose stonework, and the front not enclosed. The manager said that a ramp is available. One survey comments that “ A secure garden area would be good.” St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 20 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 to be more independent. The manager is aware of this and is involving a consultant to help make the environment more user friendly. A start has been made by putting some residents’ photographs on their bedroom door to aid identification. Most bedrooms have basic furnishings and service users are invited to bring in their own items. Three bedrooms have en-suite facilities. All of the shared bedrooms have screening to provide privacy. There has been some refurbishment since the last inspection and the provision of a new shower room. Surveys received in general comment that the home is usually fresh and clean. Three comment that some improvements are needed. One saying that “The place does need some improvement in terms of decorating and cleanliness, but the staff try very hard.” A tour of the promises found a number of light bulbs in key areas not working. Poor lighting poses risks for residents. Management dealt with this immediately. Laundry facilities are sited away from food preparation areas. The washing machine has specific programmes to deal with soiled linen. The Laundress was aware of some of the measures to take to prevent the spread of infection. There has been no outbreaks of infection reported since the home was last inspected. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care is delivered by properly recruited and trained staff to ensure the safety of service users EVIDENCE: Staff were observed responding appropriately to service users and spent time talking to them in order to understand their wishes. The rota showed that there is enough care staff on each shift taking into account times of peak activity. There is always a designated “senior” on duty and no one under the age of 21 is ever left in charge. Consideration is given to gender balance at night. Where male staff are used there is always a female on duty other than in exceptional circumstances. One staff survey says there is usually enough staff to meet the individual needs of all the people who use the service. One says there is never enough staff. Feedback from resident surveys shows that there is usually sufficient numbers of staff on duty. Relatives commented “On the whole St Margarets caters for all the needs of the residents” and “The staff are caring and friendly.” St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 22 Staff files examined showed a robust recruitment process endeavouring to ensure that only suitable people are employed. Appropriate references are taken up and an interview is conducted before anyone is offered a job. There is an induction programme that ensures new staff members are given the right information to be able to do their jobs. Staff surveys confirm that training is provided that is relevant to their role and helps them to understand the individual needs of residents. The training programme includes the mandatory training needed to meet service users basic needs such as First Aid, moving and handling and Health and Safety. Specialist training provided includes dementia care, abuse awareness and infection control. 46 of the care staff has achieved National Vocational Qualification level 2 with a further five staff undertaking the award. Two staff has completed NVQ level 3. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The newly appointed manager who has been in post for approximately one month has achieved a recognisable qualification for managing a care home. She has a number of year’s experience of managing a care home for older people. She is aware of the shortcomings in the service and is committed to improving the service offered at St Margaret’s. She has already taken some steps to achieve this. The manager meets weekly with the home owner to discuss progress and any outstanding issues. Residents say the manager is easy to talk to and approachable. This was evident during this visit. None of the surveys received on behalf of residents St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 24 and relatives commended the management of the home. One stated that although they felt that staff had residents “best interests at heart” there was not enough “guidance and direction forthcoming from management to help them” The service actively encourages the involvement of service users, family, friends and advocates. Six monthly meetings are held where ideas for improvements can be put forward. The manager has put up a notice inviting people to a “Family Meeting.” The intention is for everyone to share their views about the running of the home with a view to improving the standard of care delivered. There is a quality monitoring scheme in place that canvasses the views of residents and their relatives. The manager has developed a Service Improvement Plan, which covers key aspects of service delivery. Regular staff meetings and individual staff supervision takes place. This encourages an open and transparent management style that concentrates on the needs of service users and the proper support of staff. The management operates a system that protects service users from financial abuse in circumstances where service users money is held for safekeeping. The home works to a health and safety policy and regular safety checks are carried out. Information provided by the home owner shows that equipment is routinely serviced or tested in line with the manufacturer or regulatory body. St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 25 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 4 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Margaret`s DS0000007791.V349901.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement Comprehensive risk assessments must be completed. A plan of care must be developed to manage any areas of risk. Plans should consider the residents safety/well being balanced with their wishes to be independent. The registered person must ensure there are accurate records kept of all medicine’s administered to ensure medicines are always given as prescribed and that there is no mishandling. Handwritten entries on the MAR charts should contain all essential information, be signed & dated by the author, and then checked & countersigned by a witness to reduce the risk of mistakes when copying information from the pharmacy label. Timescale of the 30/09/07 not met The registered person must ensure that all staff authorised to handle and administer DS0000007791.V349901.R01.S.doc Timescale for action 31/12/07 2 OP9 13(2) 31/12/07 3 OP9 13(2) 31/12/07 St Margaret`s Version 5.2 Page 27 4 OP10 12(4)(a) 5 OP14 12 (2)(3) 6 OP19 23 7 OP19 23(2)(p) medicines have been appropriately trained and assessed as competent so that they can handle and record medicines safely. Timescale of the 31/10/07 not met Staff must at all times ensure the dignity of residents to assist them to maintain confidence and a positive self esteem. The provider must make sure that they provide sufficient meaningful activity and stimulation during the day. This needs to be consistently maintained. To empower residents with dementia to be independent within the home and have access to a safe and secure outside area the provider must make improvements with reference to relevant guidance. In order to maintain the safety of residents all areas of the home accessible to residents must be well lit. 31/12/07 31/12/07 31/05/08 31/12/07 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 Staff should be involved with working with the resident to develop the care plan. St Margaret`s DS0000007791.V349901.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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