Inspection on 18/01/06 for St Margaret`s Care Home

This inspection was carried out on 18th January 2006.

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

The inspector 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 Care Home 21/01/09

St Margaret`s Care Home 09/02/07

St Margaret`s Care Home 27/07/05

St Margaret`s Care Home 02/02/05

St Margaret`s Care Home 12/07/04

St Margaret`s Care Home 12/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton 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 Care Home Crossgate St Margarets Garth Durham DH1 4DS Lead Inspector Belinda Parker Unannounced Inspection 18th January 2006 09:45 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 Care Home DS0000000750.V261257.R01.S.doc Version 5.1 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 Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Margaret`s Care Home Address Crossgate St Margarets Garth Durham DH1 4DS 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) 0191 3868949 0191 3868945 Southern Cross Home Properties Limited Mrs Susan Debbie Hogg Care Home 60 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (48), of places Physical disability (5), Terminally ill (5) St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th July 2005 Brief Description of the Service: St Margaret’s is a purpose built care home. It is situated on the outskirts of Durham City. All amenities including shops, restaurants and the major tourist attractions, which include the cathedral and castle, are easily accessible. Accommodation is provided for up to 60 service users in single en-suite personalised bedrooms provided on two floors. There is a passenger lift available. The home caters for service users who require general nursing care and residential care (including 24 hour nursing care) for persons aged 65 years or older. 12 of the beds are in a separate unit on the ground floor providing residential care for service users with mental health needs. There are various lounges and dining areas located throughout the home. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 18/01/06 over a period of 6.5 hours. The manager was off duty. The Operations manager visiting assisted with the inspection. Time was spent during the inspection talking to service users and staff. We toured the building and a number of records were examined. What the service does well: What has improved since the last inspection? Since the last inspection, the company has produced a new Statement of Purpose and Service user guide which provides up to date information on the service offered in the home. These documents are soon to be given out to the people who are coming into the home and the people who already live there. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 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 Care Home DS0000000750.V261257.R01.S.doc Version 5.1 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): Standards 1,2 and 5 Clear information is available to prospective service users about the admission criteria and the service offered, including the opportunity to visit and spend time in the home. Enabling prospective service users and their relatives to make an informed decision as to whether the home can meet the needs of the individual. EVIDENCE: A Statement of Purpose and Service User Guide is in place. But these documents are to be replaced with a new updated version that includes the new company name. The Operations manager said the new Statement of Purpose and Service Users Guide when available will be given to prospective service users and the people who live in the home. These documents include information about the service offered. Enabling prospective service users and their relatives to make an informed decision as to whether they wish to move into the home. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 9 The company has introduced a new Statement of Terms and Conditions of residency. Copies of the Terms and Conditions of residency examined showed that the service user or their relative’s had signed as to their agreement. The Operations manager said prospective service users and their relatives are welcome to spend time in the home with the staff and other service users prior to admission. As well as having written information on the service provided the prospective service user is given the opportunity to see what living in the home is like. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 A review of care plans and medication recording procedures is required to ensure that service users are protected and their needs adequately met. There is evidence of a good rapport between service users and staff in a relaxed and friendly atmosphere. EVIDENCE: The care plan format is good, setting out in detail the necessary information staff require to meet the health, personal and social needs of the service user. Risk assessments are reviewed in line with the care plan monthly. One care plan examined had the monthly evaluation completed but did not actually give staff clear information as to whether their had been any change in the needs of the individual service user. Evidence of input by other health professionals was recorded. One care plan examined contained evidence of a relative signing on behalf of a service user as to their agreement with the plan of care. Another care plan examined included a copy of a quality audit by the manager, ensuring the needs of the individual service user were being met. A policy and procedure is in place for the safe handling of medication in the home. Training was ongoing for some staff on the safe handling of medication St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 11 during the inspection. MAR sheets examined for the three units showed that some hand written entries for medication had not been signed by the staff member responsible for receiving the medication into the home. Two staff members spoken to where not aware that medication should be retained in the home for a period of seven days following the death of a service user. The Operations manager said further training would be arranged. Ensuring staff adheres to the procedures to prevent service users being potentially put at risk. Staff spoken to during the inspection where able to demonstrate that they respected privacy and dignity when assisting service users with personal care. A staff member said he spends time talking with service user’s who lack capacity to support them in making choices. A service user spoken to said she enjoyed living in the home, “ This is a jolly crowd and we have a good laugh with the staff”. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This standard set was not assessed at this inspection. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 A clear complaints procedure is in place to enable service users and their relatives to make their views known if they are not satisfied with the service delivery. Robust processes are in place to ensure the people living in the home are protected from abuse. EVIDENCE: There is a clear complaints procedure in place that is displayed in the home for service user information. Since the last inspection there has been six complaints. 1x missing item of jewellery – resolved, 2 x care issues – resolved, 1 x housekeeping issue – resolved, 1 x staffing levels – resolved. The manager recorded all complaints and outcomes in the complaints register. Evidence was available to show that all staff working in the home had attended POVA (Protection of Vulnerable Adults) training. Criminal Records Bureau checks have been carried out for all staff employed in the home. Three staff members spoken to demonstrated an awareness of POVA. Staff said it was their responsibility to ensure the people living in the home were protected from abuse. There have been no POVA referrals since the last inspection. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 14 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): Standard 19, 20, 21, 23 and 24 The environment is accessible, safe and well maintained. Providing service users’ with a comfortable home to live in. EVIDENCE: On touring the home it was observed to be comfortable, accessible and well maintained. The furnishings and décor created a homely atmosphere. Within each unit there is a choice of communal seating areas internally and externally for service users to freely use. There is a choice of bathing facilities including specialist disability equipment to collectively meet the needs of the service users. Bedrooms viewed were spacious and comfortable. Many bedrooms were personalised in the chosen style of the service user. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 15 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): Standards 27, 28 and 30 Staffing levels in the home on the day of the inspection adequately met the collective needs of service users. Staff have the necessary skills and abilities to provide a good service to the people who live in and visit the home. EVIDENCE: Staff duty rotas examined showed that staffing levels in the home met the collective needs of the people who lived there. The skill mix of qualified, unqualified staff and ancillary staff is appropriate to the assessed needs of the service users. Two staff members spoken to during the inspection said all the staff worked as a team to provide the people who lived in and visited the home with a good service. Staff training records viewed show that staff attend regular training to develop their skills and abilities to enable them to meet the needs of service users. Training was ongoing in the home for some staff during the day of the inspection. A staff member spoken was able to demonstrate training he had attended which he said was beneficial to his care role within the home. Staff who have achieved NVQ2 in Care award since the last inspection is still below the required 50 level of achievement for the home. The Operations manager said there had been funding issues and change of training providers. But this issue has been addressed and the home will continue with the programme for all care staff to achieve this award. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 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): Standard 38 The manager ensures so far as is reasonable practicable the health, safety and welfare of service users, staff and visitors. EVIDENCE: Staff spoken to were able to demonstrate that they had attended health and safety training courses and were aware of the their level of responsibility for health and safety within their role. Health and safety records examined showed that all major systems and disability equipment in the home is serviced and maintained for the protection of the service users, staff and visitors. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x 3 3 x x STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 3 St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 12,13 Requirement The registered manager must ensure staff responsible for receiving medication into the home sign as received on the MAR sheet. The registered manager must ensure the monthly evaluation of individual service user’s care plans. Clearly describes if the needs of the service user has changed and any change to the plan of care required to meet those needs. Timescale for action 18/01/06 2 OP7 15 01/04/06 St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 19 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 OP28 Good Practice Recommendations The registered manager should continue with the NVQ training programme. To enable all care staff to achieve NVQ2 in Care award. To provide them with the necessary skills and abilities to adequately meet the needs of the service users. St Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 20 Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Margaret`s Care Home DS0000000750.V261257.R01.S.doc Version 5.1 Page 21 - 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. 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