Inspection on 30/05/07 for St Margaret`s Ltd

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/11/06

St Margaret`s Ltd 19/06/06

St Margaret`s Ltd 26/01/06

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 30th May 2007 09:05 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.V336834.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 Ltd DS0000006785.V336834.R01.S.doc Version 5.2 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 020 8300 2745 Mr Al-Naseer Hudda Mrs Linda Masher Care Home 22 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 22 Male or Female - OP (Old age) As agreed on the 3rd October 2006, one (1) named service user, with dementia, can be accommodated. The CSCI must be informed when this service user no longer resides at the home. 10th November 2006 Date of last inspection 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. In 2007 the provider applied to vary the category of registration for the service and can now admit older people requiring personal care or with dementia. 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 and four of these include a shower. 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 mature garden at the rear of the property. Currently some changes are being made to the communal space. The current fees ranged from £459.00 to £565. Residents paid privately for personal items, hairdressing and newspapers. St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 30th May 2007. The manager and staff assisted with the inspection. Twenty residents were in the home, one was in hospital and there was one vacancy. The service was last inspected on the 9th October 2006. The inspection included a review of information held by the Commission, a tour of the premises, and inspection of records, talking to residents, relatives, staff and the manager and reviewing compliance with previous requirements. Satisfaction surveys were also sent to residents and relatives. Management continued to improve standards for residents. At the time of this site visit a programme of redecoration and refurbishment had commenced. The programme included plans to decorate and refurbish all communal areas, convert an office on the ground floor into a second lounge, convert a small communal room at the front of property on the ground floor into a single ensuite bedroom, convert the ground floor bathroom into a shower room, refurbish the lounge, fit laminate flooring to the dining area and provide new furniture where needed. Since the last inspection the provider had applied to the Commission for a change of registration category. This change was agreed and the home can now provide care for older people with dementia. The manager said she did not plan to admit new residents until the refurbishment work had been completed. What the service does well: What has improved since the last inspection? The statement of purpose was reviewed and updated. Staff continued to work on improving care plans. Medicines were well managed. Individual staff training records were maintained and details kept of training course content. Of the fifteen care staff employed thirteen had achieved NVQ level 2 or above. St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 6 Regulation 37 reports were sent to the Commission where needed. The refurbishment programme for the premises had commenced. Staff recruitment had improved. 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 Ltd DS0000006785.V336834.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 Ltd DS0000006785.V336834.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): Standards 1, 3, 4 and standard 6 does not apply to the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents had access to relevant information about the service, an assessment of needs completed before admission and received written confirmation that the home could meet those needs. EVIDENCE: The statement of purpose had been revised to reflect the recent change in the category of resident admitted to the service. The inspector was given a copy of this and the service user guide. The service user guide had not been updated to reflect the change in category of registration. At the time of this inspection the decorators were working in the home and a number of certificates and the last report had been moved from the hallway until the work is completed. This information was available in the manager’s office for residents and others to see. Recommendation 1. St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 9 Pre-admission assessments were seen on the resident files viewed. The manager completed these when a resident visited to view the home or wherever suited the prospective resident. Some files seen also contained detailed care manager assessments. Copies of the letter sent to residents confirming the home was suited to meeting their needs based on assessment were seen on the files viewed. St Margaret`s Ltd DS0000006785.V336834.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans required more detail and must be based on assessment. Medicines were well managed and resident’s healthcare needs were met. Residents were satisfied with how they were treated by staff. EVIDENCE: Three resident’s care records were viewed. Although care planning continued to improve but needed further development to ensure they provided adequate guidance for staff on how a resident’s identified needs would be met. For example the care plan for one resident with mobility problems did not have an assessment or care plan prepared in relation to this. Another care plan for a resident who required additional support to move about in the home did have this clearly recorded in their care plan. Risk assessments had been completed in relation to residents at risk of developing pressure sores but these had not been dated or kept under review. The records generally lacked evidence of assessments. Long-term assessment had been completed for all residents but some of those seen were two years old. Not all records seen had the St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 11 resident’s name or full dates and correction fluid had been used to amend errors on some records. Staff had started to make more frequent entries on the daily care records however these provided little information and maybe staff time could be better used interacting with residents. There was some evidence of resident/relative involvement in preparing care plans. Residents and relatives seen or who provided feedback said they were satisfied with the quality of care provided. Requirement 1. Residents were registered with a G.P and staff made arrangements for residents to access dental and optical services. The G.P visited the home weekly or when called in an emergency situation. The inspector met the G.P during the site visit. The G.P said that staff used the service appropriately, had the ability to know when to refer residents and used the nurses attached to the surgery for appropriate advice and guidance. The manager had completed a course on ‘foot care’ and provided this for all residents including those suffering with diabetes, provided it was considered safe to do so. One resident confirmed they had seen the optician recently to get new glasses and residents were seen in private by the G.P during the inspection. Records were kept for accidents to residents and those seen were well completed. Notices were sent to the Commission as required by regulation 37. Residents spoken with were satisfied with how their health needs were met and relatives said staff kept them informed of their resident’s wellbeing and feedback received from relatives indicated they were satisfied with the quality of care provided. Medicines were safely stored and a medicine fridge was provided. While the decorating was in progress the medicine trolley was kept in the dining area. The trolley was secured to the wall, kept locked and the senior on duty held the keys. Administration charts were well maintained and one requirement made at the last inspection had been met. Medicines and records for three residents were checked and found to be correct. One resident managed one of their prescribed medicines and this was reflected in a care plan however there was no evidence to show that a risk assessment had been completed in relation to this. Requirement 2. Residents and relatives spoken with during the inspection said staff treated them with respect. Comments included ‘staff take a personal interest in residents’ and ‘the home provides a good homely environment’. Staff were observed interacting appropriately with residents, answering call bells and responding to resident requests for assistance. Residents said that staff were kind and helpful and one said they ‘did not interfere or stop you from doing anything’. St Margaret`s Ltd DS0000006785.V336834.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 – 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activity provision for residents could be better, residents said they were treated with respect and were satisfied with the meals. EVIDENCE: Most of the residents were seen sitting in the lounge watching T.V. and some were in their bedrooms. A hairdresser visited every Friday and residents said they enjoyed having their hair done. Unfortunately the activity organiser who was in post at the last inspection had left and had not been replaced. Care staff provided activities, however a number of residents and relatives said very little activity was provided and some residents said they found the days very long. Records of activities for three residents were viewed and showed that in May 2007 residents had the opportunity to join in watching videos, singing sessions, short walks, sitting in the garden, bingo and armchair exercises. When asked what they would like to do some residents said they were not very interested in activities, some said they enjoyed the music sessions and some said they would like to be taken out more even if only for a short walk. These comments were passed to the manager. Individual activity records were kept but social care plans must be improved to reflect individual preferences and St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 13 developed with the resident. A member of staff should be assigned to organise activities. Requirement 3 and recommendation 2. 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 and were kept informed about their resident’s welfare. Residents said they made decisions as to how they spent their day and how they liked to dress and present. They also had a choice of meal and a number said they decided on times for going to bed and getting up. There was some evidence of resident personal choice in the care plans seen, as a section on this was included. For example if a resident did not want to dress but stay in their bedroom then their wish was respected. Also some detail was noted on one care plans as to how the resident like to present. A suitably trained person prepared meals and residents were positive about this and with the meals provided. A number of residents said the food was ‘very good’. Meals were discussed during resident meetings and residents had the opportunity to comment on the menus. Menus included a choice of meal for lunch and evening meal. During lunch it was evident residents enjoyed their meal, had a choice of meal and staff offered assistance where needed. The kitchen was clean and a cleaning schedule was in place. Fridge, freezer and food temperatures were recorded. Bexley Council visited to assess the kitchen in January 2007. The home had addressed most of the recommendations made but had not yet purchased a new food thermometer. The sink unit was badly damaged and rusted inside making it impossible to keep it clean. This unit must be replaced. A number of dried foods such as herbs and spices were well out of date and must be discarded also some decanted foods had not been dated with the ‘best by’ date or the date decanted. Requirement 4. St Margaret`s Ltd DS0000006785.V336834.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to manage complaints and safeguarding adults. Management must ensure staff recognise potential abuse and report it to the appropriate agencies without delay. EVIDENCE: The home had a complaints policy in place and a system to record complaints made about the service. Since the last inspection no complaints had been made about the service to the home or the Commission. Residents and relatives spoken with said if they had a concern they would discuss this with the manager or a member of staff. The adult protection policy and procedure was adequate and a copy of Bexley’s safeguarding adults procedures was provided. All of the staff had received training on this topic and staff spoken with displayed an understanding of how to safeguard people. In the complaints file it was noted that in April 2007 a resident reported an incident of possible abuse from care staff to another resident. The manager investigated the matter, disciplined staff and issued warning letters. However this incident was not reported in line with procedure to the Commission, the local authority or other relevant agencies. The manager was advised to report the incident to the local authority and the Commission as required by regulation 37. Requirement 5 and recommendation 3. St Margaret`s Ltd DS0000006785.V336834.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, 21, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The planned refurbishment will improve and enhance the environment for residents. EVIDENCE: The home was maintained to a satisfactory standard and work had commenced on the refurbishment programme. Residents were quite animated about the work in progress and were involved with choosing colours and designs. The programme included plans to decorate and refurbish all communal areas, on the ground floor to convert an office into a second lounge, convert a small communal room into a single en-suite bedroom, convert the ground floor bathroom into a shower room, fully refurbish the lounge and fit laminate flooring in the dining area. The manager expected the work to be completed in about six to eight weeks. Care was being taken not to allow the work to interfere with the resident’s life and to help with this work to the main lounge St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 16 will be done at night. Staff recorded repairs and maintenance issues and when the maintenance technician visited and he recorded the date the work was completed. Residents and relatives described the environment as ‘homely’. Sixteen bedrooms had en-suite facilities with four having a shower unit. An assisted bath was provided on the first floor but the bathroom on the ground floor was not suitable for the residents and therefore was not being used. There were no plans to change this bathroom however after the inspection the provider agreed to change this room to a ‘wheel-in’ shower, which will be more suited to meeting the needs of the residents. The assisted bath was last serviced in January 2007. Requirement 6. Bedrooms seen were clean, tidy and free of offensive odours. Residents seen said they were satisfied with their bedrooms and were able to bring in small personal items such as photographs, ornaments, pictures and small furniture items. Bedrooms were adequately decorated and many seen were nicely personalised. A number of residents said they enjoyed quiet times in their bedrooms watching TV or reading. The home was clean, tidy and free of offensive odours. The full time domestic had left since the last inspection and the weekend person was covering the shifts. The manager said that a new domestic had been recruited and the process to employ them was in progress. Care staff continued to assist with the laundry but again the manager said that plans were in place to employ a laundry assistant. Hand washing facilities were provided in areas where waste was handled and staff had access to supplies of protective clothing. St Margaret`s Ltd DS0000006785.V336834.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 - 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff had the training needed to meet the needs of the residents however new staff must be given time to become familiar with the service, residents and staff and have an induction programme. EVIDENCE: The staff team comprised of a manager, senior carers, care assistants, domestic staff, kitchen and domestic staff. A maintenance technician visited the home on request to undertake repairs and health and safety work. The manager said that four members of staff were on duty in the morning, three in the afternoon and two waking staff at night. The staff rotas for a two-week period showed that only three staff were on duty for many of the morning shifts. This was checked with the manager who confirmed the rotas were accurate and in her opinion the staff levels provided were suited to meeting the residents needs. None of the residents or relatives raised concerns about the staffing levels. The manager was aware of the need to review staffing levels when residents with dementia are admitted. Staff displayed an understanding of the residents and how their care needs were met. From observation staff interacted politely and appropriately with residents. Comments made by residents included ‘staff are helpful and good’, ‘nobody tells you what to do’ and ‘I am quite happy and well looked after’. Recommendation 4. St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 18 The manager and senior staff in the home planned to retire in 2008 and therefore had decided not to complete NVQ training. They did attend update training relevant to their role. Thirteen of the fifteen care staff employed had achieved NVQ level 2 or above and some staff were undertaking the level 3 course. Four employee files were viewed and found to contain the information required by regulation. One issue noted was that some of the references received which were not on headed paper, did not have a company stamp or compliment slip had not been verified as genuine. None of the files had a recent photograph of the employee. The manager had taken photographs and said she would print these off the computer and add them to the files. This issue was also noted at the last inspection. An induction booklet had been introduced but there was no evidence to show that these were being completed with staff. It was also a concern to note that a new member of staff, who was new to care work, had commenced working in the home without any evidence of induction or being given time as an additional member of staff to become familiar with the service and the residents. The carer was allocated to work with an experienced carer but was included in the staffing numbers from their first shift. Requirement 7. Individual training records were maintained. These showed that since the last inspection staff had access to training such as fire safety, first aid, moving & handling, dementia care and diabetic care. Plans were in place to provide further training relevant to the service. Staff spoken with said how much they had enjoyed and benefited from the training they had received and felt they received the training needed to fulfil their roles. St Margaret`s Ltd DS0000006785.V336834.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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Attention was given to maintaining a safe environment however there was no quality assurance system in place, staff did not receive supervision and there were concerns noted in relation to safeguarding adults. EVIDENCE: The registered manager had been in post for a number of years, had the experience needed to manage the service and was registered with the Commission. The manager was supported in her role by senior cares and the provider. Reports in relation to regulation 26 visits by the registered person were sent to the Commission occasionally. There was no evidence in the home to show that St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 20 these visits had been carried out monthly as required by regulation. It was requested that these reports are sent to the Commission monthly and used to provide up to date information on the refurbishment programme. Resident meetings were held and the last one was on 16/1/07. Minutes showed that residents had the opportunity to comment on issues such as meals, staff issues, entertainment and use of communal areas. Residents and relatives seen mentioned the meetings and seemed pleased to have had the opportunity to voice their opinions on the service, give feedback and make suggestions to management. Plans were in place to send out satisfaction questionnaires to residents, relatives and others. The questionnaires sent out last year had not been collated or a report on the findings prepared. Management must ensure a quality assurance system is in place and a report of any reviews are sent to the Commission and made available to residents and others. Requirement 8. Management did not provide residents with financial management assistance. Relatives purchased personal items for residents and paid directly for services such as hairdressing. The manager confirmed that all residents had access to their personal allowance and some residents kept small amounts of cash for personal use. There was no evidence of staff induction or supervision. A supervision policy and procedure was not provided. The manager and senior staff worked with carers and took the opportunity to supervise practice however this supervision was not recorded. This issue was raised at the last inspection and the requirement made then in relation to supervision has been restated. Requirement 9. A selection of safety records were inspected, these included gas, hoist and bath, portable appliance testing, fire safety, water chlorination, hot water checks and electricity. All records and service certificates seen were up to date. Staff received moving & handling training, a system was in place to record accidents to residents and others and all staff had access to basic first aid training. Concerns were noted about the manager’s failure to report a suspicion of abuse towards a resident by care staff. See requirement 5 and recommendation 3. St Margaret`s Ltd DS0000006785.V336834.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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 2 St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement Care plans must be prepared based on assessment and with resident’s to show how all identified care needs will be met. Resident care records must include their name, the full date of the record and errors must not be amended using correction fluid. A risk assessment must be completed for resident’s wishing to manage his or her own medicines. Social care plans must be prepared for and with residents. The sink unit in the kitchen must be replaced. Foods must not be used when they have passed their ‘best by’ date. Decanted foods must be fully labelled to include the date and ‘best by’ date. All allegations or suspicions of abuse to residents must be reported in line with procedure to relevant agencies including the local authority, the DS0000006785.V336834.R01.S.doc Timescale for action 20/07/07 2. OP9 13 20/07/07 3. 4. OP12 OP15 16 23 20/07/07 20/07/07 5. OP18 13 20/07/07 St Margaret`s Ltd Version 5.2 Page 23 6. 7. OP21 OP29 23 19 Commission and the police where relevant. The ground floor bathroom must be made accessible and suitable for residents. References received for employees that are not on headed paper, do not have a company stamp or a compliment slip must be verified as genuine. New staff must have an induction period and time to become familiar with the service, residents and staff before being included in the daily staff numbers. An effective quality assurance review system must be in place. Reports on such reviews must be sent to the Commission and made available to residents and others. A policy and procedure must be in place in relation to staff supervision and staff must receive supervision as required by regulation. Evidence of staff supervision must be kept and made available for inspection. (Previous timescales of Timescales of 27/03/06, 27/07/06 and 18/12/06 were not met.) 20/07/07 20/07/07 8. OP33 24 20/07/07 9. OP36 18 20/07/07 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 OP1 Good Practice Recommendations The service user guide should be updated to reflect the recent changes to the category of resident admitted to the DS0000006785.V336834.R01.S.doc Version 5.2 Page 24 St Margaret`s Ltd 2. 3. OP12 OP18 4. OP27 home. Serious consideration should be given to recruiting an activity organiser. The safeguarding adults policy and procedure should be reviewed to ensure all staff are fully aware of the process to follow in the event of a suspicion or allegation of abuse being identified. Staffing levels in the morning should be reviewed to ensure resident’s needs are met. St Margaret`s Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Ltd DS0000006785.V336834.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!