Inspection on 20/10/05 for St Margaret`s

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Margaret`s 10/06/08

St Margaret`s 18/09/07

St Margaret`s 11/07/06

St Margaret`s 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 Unannounced Inspection 20th October 2005 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.V257692.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 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 Mrs Sandra Joan McFarlane 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.V257692.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 5 adults with a physical disability (PD) Service users to include up to 28 adults of old age (OP) Service users to include up to 5 adults with a terminal illness (TI) Total number of service users not to exceed a maximum of 28 Date of last inspection 10th May 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.V257692.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 20th October 2005 between 9am and 1.30pm. The inspector met with the Registered Manager (elect), the deputy manager, staff on duty, and 3 service users. During the course of the day the inspector observed the service users being attended to by staff and noted that they were treated with due respect. Service users informed the inspector that their expectations of being in a care home were being met and that they were satisfied with the services offered. The inspector visited all parts of the building, which was seen to be clean and pleasantly decorated throughout. What the service does well: What has improved since the last inspection? What they could do better: St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 6 As above, the appointment of a Registered Manager (elect) should assist the home to better meet the requirements and recommendations identified in this inspection, which are predominantly of a managerial nature. 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.V257692.R01.S.doc Version 5.0 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.V257692.R01.S.doc Version 5.0 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, 2, 6 Service users are generally provided with the information they need, though some documentation is in need of review. EVIDENCE: The home has a Statement of Purpose and Service User Guide, though both of these needs to be reviewed (dated 2003). The Registered Provider must review and amend to Statement of Purpose and Service User Guide to ensure the accuracy of the information provided. Each service user receives a Statement of Terms and Conditions, which is signed by both parties. Service users spoken with were complimentary about the care provided, and the attentiveness and kindness of the staff. Though not specifically explored at this inspection, there is evidence of ongoing staff training relevant to the care provided at the home. Standard 6 is not applicable, as the home does not provide intermediate care. St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 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): These standards were covered at the last inspection and were not inspected this time, though it was noted that service users were treated with dignity and respect. EVIDENCE: St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 The routines of daily living and activities made available are flexible and varied. Service users receive visitors at any reasonable time throughout the day. EVIDENCE: Three service users spoke positively of the lifestyle available to them at the home, and confirmed that they are able to receive visitors without restriction. They said that the entertainments provided by the home were sufficient for them, and that staff helped to support and assist them. A visitor’s book is kept in the entrance to the home and shows regular and frequent visitors to the home. The service users were complimentary about the staff and the care provided, and they spoke highly of the food. 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, from where it is served. St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 11 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): 18 Comments from service users were positive, but the home must develop its Protection Of Vulnerable Adults procedure. EVIDENCE: The home’s Protection Of Vulnerable Adults procedure was not evident in the policies and procedures manual, and the recently appointed Registered Manager (elect) was not aware of the status of this document within the home. The Registered Provider 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 Provider 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. St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 12 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): 21, 22, 24, 25, 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, and a new electric hoist has recently been purchased. Access between floors is aided by a passenger lift. Service user rooms were seen to be clean, comfortably furnished and personalised to varying degrees. St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 13 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 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 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.V257692.R01.S.doc Version 5.0 Page 14 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): 28 A sufficient number of staff is on duty to meet the service user’s needs. There is evidence of ongoing staff training, though this could be improved. EVIDENCE: The home has recently undergone a change in management. The newly appointed Manager is making application to the Commission for Social Care Inspection to be the Registered Manager. The home has a duty rota that accurately reflected the number and skill mix of staff on duty during the inspection. Staffing levels are generally as follows: AM – 1 nurse 5 carers PM – 1 nurse 4 carers Evening – 1 nurse 4 carers Night – 1 nurse 2 carers There were 23 service users resident at the time of the inspection. There is an active NVQ programme, though the actual percentage of staff qualified to NVQ was not ascertained at this time. St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 15 The Registered Provider should ensure that the induction programme for new staff complies with the National Training Organisation (Skills for Care) programme (www.topss-england.net). St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36, 37 Service user comments were positive and it is hoped that the recent appointment of a Registered Manager (elect) will improve the ethos and leadership to the benefit of the service user’s best interests. EVIDENCE: Service user comments were positive and it is hoped that the recent appointment of a Registered Manager (elect) will improve 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. A sample of service user financial records was inspected and seen to be accurate. Records are supported by receipts, and storage is secure. As discussed at the time with the Registered Manager (elect), the Registered St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 17 Provider should consider monthly invoicing service users/representatives for costs in order to minimise the handling and storage of service user monies. The Registered Provider must provide the Commission for Social Care Inspection with a copy of the home’s annual accounts, or a reference from a bank expressing an opinion as to the Registered Provider’s financial viability. The Registered Provider must ensure that care staff receive formal supervision (as detailed in 36.3) at least six times per year. Risk-assessments are in use, but not all are dated and these should be reviewed to ensure accuracy and also in order to identify any action required. The home’s policies and procedures are not dated. The Registered Provider should review and amend all the home’s policies and procedures to ensure that all relevant areas are covered, and reflect current good practice. COSHH information is available, though it was suggested that the Registered Manager (elect) cross-reference the information available with the actual products used in the home. There was documentary evidence of care staff undertaking manual handling training. The inspector was advised that one member of staff is undertaking a Health & Safety course. The accident book was seen to be in order. The recently appointed Registered Manager (elect) stated that he would be exploring the possibility of identifying key staff for specific responsibilities (such as Health & Safety, Link Nurses). St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 X X 3 3 X 3 3 2 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 2 X 2 2 X St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4, 5 Requirement The Registered Provider must review and amend to Statement of Purpose and Service User Guide to ensure the accuracy of the information provided. The Registered Provider 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 Provider 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. The Registered Provider must provide the Commission for Social Care Inspection with a copy of the home’s annual accounts, or a reference from a bank expressing an opinion as to the Registered Provider’s financial viability. DS0000009258.V257692.R01.S.doc Timescale for action 01/01/06 1. OP18 13.6 01/12/05 2. OP34 25 31/01/06 St Margarets Version 5.0 Page 20 3. OP36 18 (2) The Registered Provider must 01/12/05 ensure that care staff receive formal supervision (as detailed in 36.3) at least six times per year. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP26 Good Practice Recommendations 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. The Registered Provider should ensure that the induction programme for new staff complies with the National Training Organisation (Skills for Care) programme (www.topss-england.net). The Registered Provider should consider monthly invoicing service users/representatives for costs in order to minimise the handling and storage of service user monies. Risk-assessments are in use, but not all are dated and these should be reviewed to ensure accuracy and also in order to identify any action required. The Registered Provider should review and amend all the home’s policies and procedures to ensure that all relevant areas are covered and reflect current good practice. 2. OP28 3. 4. OP35 OP37 St Margarets DS0000009258.V257692.R01.S.doc Version 5.0 Page 21 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.V257692.R01.S.doc Version 5.0 Page 22 - 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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