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Inspection on 27/07/05 for St Margaret`s Care Home

Also see our care home review for St Margaret`s Care Home for more information

This inspection was carried out on 27th July 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Feedback from service users and relatives indicated that people feel satisfied with the care provided at St. Margaret`s Care Home. Comments received ` It is a very friendly home. Every one makes you welcome. All the staff are great.` Staff were described as very caring, and service users were very appreciative of those who assisted with social activities. Staff, relatives and service users described the manager as approachable and helpful.

What has improved since the last inspection?

Service users spoken to felt that there had been a significant improvement in the quality of social activities offered since the last inspection and those who had been involved in the recent Life Story book had particularly enjoyed this activity.

What the care home could do better:

The homes statement of Purpose, Service User Guide and Statement of Terms and Conditions requires amendment to reflect the recent change of company. The manager advised that new brochures have been ordered but are not yet available. Staff training with regard to NVQ must continue to ensure that the required standard is achieved within the timescale.

CARE HOMES FOR OLDER PEOPLE St Margarets Care Home Crossgate St. Margarets Garth Durham DH1 4DS Lead Inspector Sue Lowther Unannounced Inspection 27 July 2005 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 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 Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Margarets Care Home Address Crossgate St Margarets Garth County Durham DH1 4DS 0191 3868949 0191 3868945 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Home Properties Ltd Mrs Susan Hogg Care Home 60 Category(ies) of OP Old age - 48 registration, with number PD Physical disability - 5 of places TI Terminally ill - 5 DE(E) Dementia - over 65 - 12 St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th February 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 of the 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 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 lounge and dining areas located throughout the home. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. CSCI has a statutory duty to inspect all care homes at least twice a year. This unannounced inspection was carried out in accordance with this duty. The inspection took place on the 27trh July 2005 between the hours of 9:30 am and 3:30pm. Records were examined and a tour of the building took place. Time was spent talking to 20 service users, 8 staff and 2 relatives. In line with current CSCI policy on Proportionality, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion will be raised during the next inspection of the home. What the service does well: What has improved since the last inspection? Service users spoken to felt that there had been a significant improvement in the quality of social activities offered since the last inspection and those who had been involved in the recent Life Story book had particularly enjoyed this activity. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3&4 Information is given to prospective service users to help them make an informed decision about moving into St Margaret’s Care Home however this requires updating to reflect the new company. Appropriate assessment procedures are in place EVIDENCE: Copies of the Statement of Purpose and Service User Guide were available within the reception area of St Margaret’s Care Home, which require updating to reflect the new company. Copies of the most recent inspection report were also available. Copies of the Terms and Conditions document was viewed within service user documentation and contained all of the information required. Assessments from Care Managers are obtained for all new admissions funded by the Local Authority. The home also carries out its own assessments on service users to ensure that the home can meet the needs of the people who live there. Six of these were examined and were found to be comprehensive. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 standard(s) These standards/outcomes area were not assessed during the course of this inspection. They will be examined at the next inspection EVIDENCE: St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 standard(s) 12,13,14&15 The lifestyle experienced in the home matches the preferences and satisfies the social, cultural, religious and recreational needs of service users. EVIDENCE: The home has dedicated staff that organise activities and several activities were ongoing during the inspection process on both a group and individual basis. Service users spoken to confirmed that they are given a choice of activities and had particularly enjoyed recently compiling a life story book on a group basis. The people who live there can have visitors at a time convenient to them and can have visitors in one of the communal lounges or in their own room. The menus were examined and the meal observed at lunchtime. The inspector noted that the people were given a choice of food and can eat in one of the dining rooms or in their bedroom. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 standard(s) These standards/outcomes area were not assessed during the course of this inspection. They will be examined at the next inspection. EVIDENCE: St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 standard(s) 22,25&26 The standard of the environment within the home provides service users with a homely and attractive place to live in. EVIDENCE: St Margaret’s Care Home was purpose built and meets the room sizes as stated in the National Minimum Standards. All bedrooms are for single occupancy and have ensuite toilet and washbasin. There are a number of spacious sitting and dining areas available throughout the home, with the upper level being reached by a passenger lift or stairs. The grounds are pleasant and suitable for wheelchairs. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 13 During the tour of the building and whilst talking to people in their bedrooms, the inspector saw that service users could bring in their own furniture and belongings should they wish to do so. There was a range of specialist equipment seen around the home and bathrooms were noted to be appropriately equipped. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28&29 Staff are generally trained and competent to do their job, although the home have not achieved the standard for the ratio of care staff qualified to NVQ Level 2. The procedures for the recruitment of staff are robust and offer protection for the people who live there. EVIDENCE: The staff files reviewed indicated that all of the required recruitment checks are now made before a new member of staff starts to work in the home. After talking to staff and reviewing records it was confirmed that recent training has taken place in the areas of care planning, nutrition, food hygiene, fire safety, first aid, moving and handling and ‘Protection of Vulnerable Adults. The manager advised that although the home does not yet meet the required 50 ratio for staff qualified to NVQ Level 2 or above, 15 members of staff have almost completed the course and if they are successful this will ensure that the 50 target is exceeded. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35,36&37 The home has a Registered manager in place who is positive towards the provision of a good standard of care delivery to service users. The home regularly reviews its performance through seeking the views of service users, staff and relatives. EVIDENCE: Feedback from service users, staff and relatives confirmed that the manager is approachable and friendly. There was evidence that quality assurance systems are in place with regular consultation at home and company level taking place with service users. This is in the form of service user and relative meetings, regular surveys and monthly external audits by a company representative. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 16 Individual records examined for money held in the home on behalf of service users were up to date and accurate. Evidence was seen in staff files of monthly supervision, and staff confirmed during discussion that this takes place. The company policies and procedures available within the home are reviewed on a regular basis to ensure that as far as is practicable service users rights and best interests are safeguarded. St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 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 3 15 3 COMPLAINTS AND PROTECTION x x x 3 x x 3 3 STAFFING Standard No Score 27 x 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 3 x 3 3 3 x St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 18 NO 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 OP 1 & 2 Regulation 4, 5, 6 & Schedule 4 Requirement The Statement of Purpose, Service User Guide and Statement of Terms and Conditions requires ammendmnent to reflect the new company. Excluding the Registered Manager and Registered Nurses, a minimum ratio of 50 of staff should be trained to NVQ Level 2 or equivalent by 31/12/05. Timescale for action 31/10/05 2. OP 28 18 31/12/05. 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 Good Practice Recommendations St Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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 Margarets Care Home B54 S750 St Margarets V229019 270705 Stage 4.doc Version 1.40 Page 20 - 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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