Inspection on 09/02/07 for St Margaret`s Care Home

This inspection was carried out on 9th February 2007.

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 18/01/06

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 Mrs Sue Lowther Unannounced Inspection 09:30 9 & 27 February 2007 th th 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.V319946.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 Care Home DS0000000750.V319946.R01.S.doc Version 5.2 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 Susan Elizabeth Nelson 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) St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: St Margarets 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. Fees charged are between £364:50p and £594. This does not include toiletries, hairdressing, chiropody and newspapers. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of St Margaret’s Care Home took place on the 9th & 27th February 2007. Records were examined and a tour of the building took place. Time was spent talking to service users, staff and relatives. The manager supplied some information on a pre inspection questionnaire. Information from this survey and discussions on the day of inspection are reflected in the report. The inspection focussed on key standard outcomes for service users. What the service does well: What has improved since the last inspection? Care plans are now comprehensive and well written. They are also now evaluated on a monthly basis as required following the last inspection. This will help staff make sure that each resident gets the support and assistance that is needed. The last inspection report required that medication received into the home is signed for by staff on the medication administration record. This is now being carried out. A programme of redecoration has taken place and service users said that this had made the building feel homely. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Margaret`s Care Home DS0000000750.V319946.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 Care Home DS0000000750.V319946.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): Standard 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment procedures are in place to ensure that the home can meet all of the needs of the people who go to live there. The home does not provide intermediate care. Therefore assessment of Standard 6 is not required. EVIDENCE: Care plans examined showed that a full pre-admission assessment had been carried out. The manager said that she visits the prospective service user before admission to the home. The service user and their relatives are involved in this process. This is to ensure that the home can meet the needs of the prospective service user. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 9 Service users and relatives said that they were given enough information to decide whether the home was suitable. One service user said, “My husband and daughter came to look around the home many times before I came to live here. They were given a brochure which contained all of the information I needed”. St Margaret`s Care Home DS0000000750.V319946.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): Standards 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place to ensure that health care needs of service users are met. Service users can be confident that their privacy and dignity is protected and that they are treated with respect. EVIDENCE: The manager said that all of the service users have care plans. Four were looked at during the inspection. These were comprehensive and well written and are now evaluated monthly as required following the last inspection. This will help staff make sure that each resident gets the support and assistance that is needed. The inspector spent time with the service users and saw that they are well cared for and comfortable. Records examined showed that service users receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 11 Medication systems were looked at during this inspection. The home uses a monitored dosage system. All of the medication was signed for on the medication administration records. The manager carries out a monthly audit and any areas of concern are addressed immediately. The last inspection report required that medication received into the home is signed for by staff on the medication administration record. This is now being carried out. Service users and relatives said that the staff are polite, friendly and treat people with respect. One relative said, “The staff here are marvellous, I find them very helpful and the quality of care to be first class”. Another said “I am generally very pleased with the way my relative is cared, she is always clean and comfortable. One service user said, “I appreciate the hard work, patience, care and commitment offered by staff”. All of the people spoken to confirmed that their privacy is maintained. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities are varied and provide recreation for some of the people living in the home. Family and friends can visit the home at any time and are made to feel welcome. The meals are of a good standard. Menus are varied and service users are given a choice. EVIDENCE: The home employs an activities co-ordinator. Activities take place both inside and outside of the home. The indoor activities include arts and crafts, music afternoons, reminiscence and quizzes. Outside entertainers visit the home on a regular basis. One service user said, “The activities over Christmas were excellent. I had a really good time”. Service users said they are encouraged to make choices about their lives. One said “I can get up and go to bed when I want and the girls give me a bath when I want one”. Another said “I like to spend time in my room, staff pop in to see if I need anything”. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 13 Most of the people said that they liked the food and that a choice is usually available. One service user said, “ The food is good and I have a choice most of the time”. One relative said, “I visit quite regularly when the food is being served. It looks good”. Nutritional assessments are undertaken and special diets are prepared when required. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 14 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): Standards 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse. EVIDENCE: Information is available for service users and visitors to the home on how to make a complaint. Service users and families views are obtained through regular contact and an open door policy. Service users and relatives said that they feel confident in discussing any issues with the manager. One person said, “I tell the manager or deputy when I have a problem and they sort it out quickly”. A record of complaints is kept which shows that the home has an accessible system in place for use by service users, relatives, staff and visitors. Training in adult protection is provided for all of the staff during their induction and is updated on a regular basis. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 15 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): Standards 19, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained. It is decorated and furnished to a good standard and provides a homely environment for the people who live there. EVIDENCE: The inspector looked around the home and found it to be light and airy. A programme of redecoration has taken place and service users said that this had made the building feel homely. Individual bedrooms and communal areas were suitably furnished and decorated in a style liked by people living there. Residents spoken to said they liked being able to bring into the home small items of furniture along with pictures and photographs to make there own rooms more pleasant and feel more like home. Some of the coffee tables in St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 16 individual bedrooms were showing signs of wear and tear. An audit of all coffee tables should be undertaken and replacement tables purchased where needed. The communal areas of the home were clean and residents confirmed that their bedrooms were also cleaned to a good standard. A visitor commented that the home was always nice and clean. There were no unpleasant smells apparent on the day of inspection. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 17 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): Standards 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are appropriately recruited, trained and in sufficient numbers to meet the needs of the people who live in the home. EVIDENCE: The home had staff files in place, which provided evidence that the appointment of new members of staff is made through proper recruitment processes. This includes the vetting of staff through the use of Criminal Record Bureau (CRB) checks, Protection of Vulnerable Adult checks (POVA) and written references. The staffing rotas were examined during the inspection. Staff felt that there are sufficient staff to meet the needs of the people who live in the home. One service user said “Staff are busy but will generally stop for a chat when they have time”. One relative said “Although staff are busy they always make time to answer questions and offer advice if we request it”. The last inspection report recommended a minimum ratio of 50 of care staff be trained to NVQ Level 2 or above in care. The manager said that 71 of staff are now trained to that level. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 18 Training has also taken place in food awareness, protection of vulnerable adults, moving and handling, customer care and fire training. Certificates to confirm this were seen in staff files. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 19 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): Standards 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the home is well managed and they are given the opportunity to comment on how the home is run. Policies and procedures are in place to safeguard their health, safety and wellbeing. EVIDENCE: The manager is a qualified nurse and has several years experience in working with older people. She has applied to undertake an appropriate management qualification but does not know when this will start. All staff spoken to confirmed that the manger is always available for support. One said, “The manager is really good, she is a great support”. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 20 The manager said that survey had been carried out recently and that she had made some changes in the home based on the answers received. Service user and relatives views are obtained through regular contact and an open door policy. Monthly relative and service user meetings are held which give people the opportunity to raise and discuss any concerns they may have. The company carries out a quality assurance and monitoring audit on a monthly basis. This covers all aspects of care delivery and environmental issues. Copies of these were available in the home. Pocket monies are kept in the home for people who request this. Two signatures are obtained and receipts are kept to ensure service users’ financial interests are safeguarded. The manager confirmed that the home carries out regular health & safety checks. The inspector checked some of the records. Those viewed were up to date. St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 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 Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. ‘ Refer to Standard OP24 OP31 Good Practice Recommendations St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. Extracts may not be used or reproduced without the express permission of CSCI St Margaret`s Care Home DS0000000750.V319946.R01.S.doc Version 5.2 Page 24 - 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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