Inspection on 26/01/06 for St Margaret`s Ltd

This inspection was carried out on 26th January 2006.

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 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 Ltd 05/05/09

St Margaret`s Ltd 08/05/08

St Margaret`s Ltd 30/05/07

St Margaret`s Ltd 10/11/06

St Margaret`s Ltd 19/06/06

St Margaret`s Ltd 18/07/05

St Margaret`s Ltd 09/12/04

St Margaret`s Ltd 23/06/04

St Margaret`s Ltd 05/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Margaret`s Ltd 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR Lead Inspector Ms Pauline Lambe Unannounced Inspection 26th January 2006 10:00 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 Ltd DS0000006785.V275273.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 Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Margaret`s Ltd Address 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR 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) 020 8300 2745 Mr Al-Naseer Hudda Mrs Linda Masher Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 Male or Female - OP (Old age) Date of last inspection 18th July 2005 Brief Description of the Service: St. Margarets is privately owned by Mr and Mrs Hudda and has been registered since 1971. The home is registered to provide care and accommodation for 22 older people. The Home is a large detached two-storey property, which includes a purpose built extension. A lift is available for the residents. St Margarets is located in a residential area close to transport and shops. There are three double and sixteen single bedrooms, fourteen of which have en suite facilities. There are two bathrooms with WCs and three further WCs. A small lounge is situated at the front of the building. In addition there is a large lounge/dining room, which looks onto the attractive garden at the rear of the property. Residents have access to health care services via the local GP practice. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A regulation and pharmacy inspector from the Commission completed this unannounced inspection. The pharmacy inspection was completed in 2.75 hours and the rest of the inspection in 6.5 hours. The manager was in charge and 20 residents were in the home with one resident in hospital. The inspection process included reviewing the service file, speaking to residents, relatives, staff and management. Inspecting records required by regulation, undertaking a tour of the premises and a review of compliance with requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Efforts must be made to involve residents or their representatives in preparing care plans and social care plans. Meds. Staff must have access to clean adult protection procedures and a copy of Bexley Adult Protection procedures should be kept in the home. Staff must be recruited in line with regulation and must have access to regular supervision. The registered Person must ensure visits are made to the home as required by regulation 26. A quality assurance system must be introduced and efforts made to obtain the views of residents and relatives about the quality of the service. A fire risk assessment and an evacuation policy must be in place for the home. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 6 Consideration should be given to making the small front lounge more ‘user friendly’ for residents and to updating the overall décor. Management should prepare a maintenance and refurbishment programme to show how this will be achieved. A system should be implemented to ensure maintenance and safety systems are completed routinely. 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 Ltd DS0000006785.V275273.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 Ltd DS0000006785.V275273.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): 2, 3 and 4. Standard 6 was not applicable. Contracts for service were not seen on this occasion. Pre-admission assessments and care manager assessments were completed for prospective residents. EVIDENCE: The manager said that the provider kept the contracts for service so these were not available to inspect. This standard will be reviewed at the next inspection. Since the last inspection the manager had introduced a pre-admission assessment form. The manager said she did not go out to do assessments but completed these when prospective residents visited to view the home. Copies of care manager assessments were also seen in the files viewed. Written confirmation was sent to residents stating the home could meet their needs based on assessment. Requirement 1. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 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): 7, 8 and 9. Improvements had been made to care planning and medication management. Attention was given to meeting the healthcare needs of residents and residents said they were treated the way they wished. EVIDENCE: Staff were complimented on the improvements made to preparing individual care plans. Four care plans were viewed and included assessments and risk assessments. Care plans had been developed based on assessment and these showed how needs were to be met. There was however no evidence that residents or their representatives had been involved in this process and a number of residents confirmed that they had not been involved with care planning. Care plans were reviewed 6 monthly or when care needs changed. Residents were supported to access health care through G.P services. Staff made arrangements for residents to access dental, optical and chiropody services. Records were kept for all accidents to residents and those seem were well completed. Regulation 37 notices were sent to the Commission as required by regulation. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 10 The Commission pharmacist inspected medicine management. Overall improvements had been made to this and a separate report has been sent to the provider of the inspection findings. The requirements made by the inspector have been included in this report. A number of residents said they were satisfied with the way care was provided and the respectful way staff treated them. Requirements 2, 3, 4, 5, 6 and 7. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 11 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. 14 and 15. Efforts must be made to show that residents were involved in planning the activity programme. Residents confirmed they could have visitors at times to suit them and also said that they enjoyed their meals. EVIDENCE: The majority of residents were seen sitting in the lounge watching T.V. Activity records showed residents participated in a varied activity programme. Staff said activities were provided in the afternoons. However a number of residents said they got bored, found the days long and watched too much T.V. They said they did enjoy some activities but felt more could be provided. In view of these comments it would be advisable to ensure residents were involved in planning the activity programme. The registered person should use this as an opportunity to make better use of the small lounge at the front of the property. This room, if properly furnished, decorated and fitted, including fitting curtains, would give residents an alternative to the main lounge. It would give residents a choice as to where to sit and another area to relax in and to enjoy music, videos, greet visitors or enjoy activities in small groups relevant to ability and preference. The home had an open visiting policy and residents said they enjoyed visits and outings with family and friends. Visitors seen said they were made feel welcome by staff when visiting the home. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 12 Residents said they made decisions as to how they spent their day and how they liked to dress and present. By involving residents with care planning the home could evidence the level of personal choice residents made. There were no concerns raised by residents in relation to meals provided. A number of residents said the food was ‘very good’. During lunch it was evident residents enjoyed their meal, had a choice of meal provided and staff offered assistance where needed. Requirements 2 and 8 and recommendations 1. St Margaret`s Ltd DS0000006785.V275273.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): 16 and 18. The home had a complaints policy and procedure. The policy on adult protection had been reviewed but there was no procedure in place. EVIDENCE: The home had an adequate complaint policy in place and a system to record complaints made about the service. Since the last inspection one complaint had been made to the home and none to the Commission. A number of compliments had been sent to the home expressing satisfaction with the care provided. Since the last inspection the policy on adult protection had been reviewed. However there was no procedure in place to show staff what action they must take should this be needed. The manager was advised of the need to have a clear procedure in place for staff to follow in the event of suspicion or allegation of abuse. A copy of Bexley Council’s adult protection procedures should be available to staff and the inspector advised the manager how to get a copy of this. In discussion with staff it was evident they had a working understanding of adult protection and what to do if this was suspected. Requirement 9. St Margaret`s Ltd DS0000006785.V275273.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): 19, 22, 23 and 26. The environment was clean, tidy and adequately decorated. The small lounge on the ground floor should be put to better use for resident comfort. A number of residents said they were satisfied with their bedrooms. EVIDENCE: The home was generally clean, tidy and adequately maintained. Making the small lounge comfortable and accessible to residents would enhance the communal space. Although the home was adequately maintained the environment was looking tired and dated. At the last inspection it was suggested the registered person review the environment and prepare a maintenance and refurbishment programme. This had not been done and has been requested again in this report. Staff recorded repairs and maintenance issues and when the maintenance technician completed the work he ticked the job off in the book. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 15 Following the inspection the Commission were informed that the mobile hoist was last serviced on 10/2/06. Grab rails were fitted where needed and residents had access to a call system when they needed assistance. Three bedrooms were assessed against the standards and found to comply. Residents said they were satisfied with their personal space. A number of bedrooms viewed were nicely personalised with resident’s own belongings. Staff had access to protective clothing and hand washing facilities were provided where waste was handled. The laundry was clean and tidy and seemed to be well managed. Resident’s personal clothing was neatly stored, nicely laundered and sensitively labelled. Recommendations 1 and 3. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 16 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): 27 and 29. The registered person must ensure staff are recruited in line with the requirements of regulation. EVIDENCE: Staff rotas sent to the commission showed that adequate staffing levels were maintained. Staff displayed an understanding of residents needs and were observed interacting with them appropriately. Four employee files were inspected. None of these included all the information required by regulation. Missing information included proof of identity, two written references and clarity round who requested the CRB checks. Three CRB checks had been done by a different provider. A requirement made at the last inspection in relation to recruitment had not been met. Requirement 10. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 17 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): 33, 36 and 38. The home did not have a quality assurance system in place and regulation 26 reports were not sent to the Commission. Staff did not receive supervision and more attention was needed to ensure maintenance issues were addressed routinely. EVIDENCE: Management must ensure that systems and procedures in place running the service complied with current legislation and the national minimum standards. For example up to date policies and procedures must be provided and kept under review, residents and relatives must be involved with care planning and planning the activity programme and a quality monitoring system must be in place to review and improve the service. The Commission has not received any reports in relation to regulation 26 visits by the registered person. No resident or relative meetings were held to obtain feedback about the service and no quality assurance system was in place. All of the above issues were St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 18 discussed with the manager. The home did not have a facsimile machine but since the inspection the Commission have been informed that one has been provided. No formal staff supervision was being provided at this time. The manager and senior staff worked with carers and took the opportunity to supervise their practice. A selection of safety records were inspected. A full inspection of the electricity supply had been completed and remedial works identified completed since the last inspection. All windows above the ground floor had restricted openings fitted since the last inspection. The lift was overdue a service and at the time of writing this report the manager had confirmed verbally to the Commission that this had been done on 1/2/06. Also water chlorination had been done on 3/2/06. The fire alarm was overdue a service and again the Commission received verbal confirmation that this was arranged for 17/2/06. The home did not have a fire risk assessment for the building or an evacuation policy and a recommendation in relation to this was made in the last inspection. This report includes this as a requirement. The home did not have a health and safety policy signed by the registered person and the manager agreed to address this. The maintenance records for other safety systems inspected were up to date. Requirements 11, 12, 13, 14 and 15 and recommendation 4. St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 19 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 2 3 3 X X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 3 3 X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 1 X 2 St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 20 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 OP2 Regulation 5 Requirement Timescale for action 20/03/06 2 OP7 15 3 OP9 13 4 OP9 13 The Registered Person must ensure each resident has a contract for service and that this reflects the fees paid and who is responsible for paying them. The Registered Person must 20/03/06 involve residents or their representatives in preparing care plans including social care plans. The Registered Person must 20/04/06 ensure a policy and procedure for self-administration of medicines is developed and the policy and procedure for storage of medicines is reviewed. 20/03/06 The Registered Person must ensure All medicines are fully labelled and blank administration records are obtained to record medicines received mid month. Allergies must be recorded on all administration records, or “nil known”. Records of receipt are kept for all medicines, including those received mid month. When direction for medicine are changed by the doctor, the new directions must be clearly DS0000006785.V275273.R01.S.doc Version 5.1 St Margaret`s Ltd Page 21 5 OP9 13 6 OP9 13 7 OP9 13 8 OP12 16 9 OP18 13 10 OP29 19 recorded on the administration record, and the directions on the label must be altered and initialled by the doctor, or a new label obtained from the pharmacist. When variable doses are prescribed, the amount actually administered must be recorded. The Registered Person must ensure medicines requiring refrigeration are stored in a refrigerator and the minimum, maximum and current temperature of the medicines refrigerator is recorded daily. Oxygen cylinders must be kept in trolleys. The Registered Person must ensure that staff receive updated training on handling and management of medicines and Oxygen administration. The Registered Person must ensure that staff are audited on their adherence to policies and procedures relating to medicines. The Registered Person must ensure residents are consulted about their social interests and are consulted about the programme of activities arranged by or on behalf of the care home. (Timescale of 28/10/05 was not met). The Registered Person must make arrangements to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. Staff must have access to clear policies and procedures as to the action they must take if they become aware of or suspect incidents of adult abuse. (Timescale of 30/09/05 was partially met) The Registered Person must not DS0000006785.V275273.R01.S.doc 20/04/06 20/04/06 20/04/06 20/03/06 13/03/06 13/03/06 Page 22 St Margaret`s Ltd Version 5.1 11 OP33 26 12 OP33 24 13 OP36 18 14 OP38 23 15 OP38 16 employ staff to work in the home unless the person is fit to work in the home and the information required in schedule 2 has been obtained. (Timescale of 30/09/05 was not met.) The Registered Person must ensure visits are made to the home as required by this regulation and a copy of the visit report must be sent to the Commission. The Registered Person must establish a system to review and improve the quality of care provided in the home. The system must include consultation with residents and their relatives and the Commission must receive a report of any review conducted. The Registered Person must ensure the home has policies and procedures in place in relation to staff supervision and that staff receive supervision as required by regulation. Evidence of staff supervision must be kept and made available for inspection. The Registered Person must ensure a fire risk assessment is done on the building and the home has an evacuation policy and procedure in place for staff to follow in the event of a fire. A copy of these documents must be sent to the Commission. The Registered Person must ensure a system is in place to maintain and service safety systems on a regular basis and that staff re provided with a health & safety policy. 27/03/06 27/03/06 27/03/06 20/03/06 20/03/06 St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 23 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 OP12 Good Practice Recommendations The Registered Person should give serious consideration to enhancing the environment of the small lounge so that residents could use this as an alternative to the main lounge, as a place to greet visitors and to enable individual or small group activities to take place. The Registered should ensure staff employed in the home had access to a copy of Bexley Council’s adult protection procedures. The Registered Person should ensure a programme of routine renewal of the fabric and decoration of the premises is produced and implemented. A copy of this programme should be sent to the Commission. The Registered Person should ensure resident and relative meetings are held to enable feedback to be given about the service. 2. 3. OP18 OP19 4. OP38 St Margaret`s Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Ltd DS0000006785.V275273.R01.S.doc Version 5.1 Page 25 - 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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