Inspection on 05/05/09 for St Margaret`s Ltd

This inspection was carried out on 5th May 2009.

CQC found this care home to be providing an Adequate service.

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 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 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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE St Margaret`s Ltd 3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HR Lead Inspector Maria Kinson Unannounced Inspection 10:45 5th and 8th May 2009 DS0000006785.V375321.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Margaret`s Ltd DS0000006785.V375321.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 Manager post vacant Care Home 22 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 22 8th May 2008 Date of last inspection Brief Description of the Service: St Margaret’s is registered with the Care Quality Commission (CQC) to provide personal care and accommodation for 22 older people with dementia. The home is located in a residential area of Sidcup and is within walking distance of a main line railway station, local bus services and shops. The home consists of a large detached two-storey house, with a purpose built extension and passenger lift. There are three double and sixteen single bedrooms, fourteen of which have en suite facilities and four of these include a shower. At the front of the building there is a shared lounge and at the rear of the property there is a large lounge/dining room, which looks out onto the garden. There are bathing facilities on each floor. The current fees range from £478.00 to £700 per week (this information was supplied to the commission on 03/08/08). Residents are responsible for purchasing personal items and services such as toiletries, hairdressing and newspapers from their own funds. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was unannounced and was carried out over two days in May 2009. The inspector spent fifteen hours in the home. Before we visited the home we looked at all the information that we had received, or asked for, since the last key inspection. This includes complaints and concerns, notifications and the Annual Quality Assurance Assessment (AQAA) form. We sent surveys to some of the people that work, live and visit the service, to obtain their views about the home. We received five responses, three from staff and two from relatives. During the inspection we spoke to two residents, four visitors and three members of staff. The feedback that we received helped us to form a judgement about the service. Some of the comments that people made about the home are included in this report. During the visit we examined some of the records that were kept in the home, observed staff supporting residents to eat and drink, move around the home and take their medicines. We visited all of the communal areas and viewed a selection of bedrooms on each floor. There were 18 people living in the home at the time of the inspection. What the service does well: People that expressed an interest in the service could visit the home to look at the facilities and ask questions. Staff monitored health issues and sought advice from other professionals, where necessary. Residents were able to make decisions about where and how they spent their time. Staff spent time talking to residents and listened to their views. The menu was varied and residents told us that they always enjoyed their meals. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 6 The building was clean, fresh and well maintained. Residents could arrange their rooms to suit their needs. Relatives who to speak to if they had concerns and said the new manager was approachable. Regular checks and inspections were carried out to ensure that equipment was in working order and was safe for use. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide were not reviewed and updated at regular intervals. This meant that some information about the service was out of date. Staff identified resident’s needs but did not always develop a plan to show how they would support the person with these issues. Good record keeping is essential to the provision of safe and effective care. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 7 The balance of some medicines did not correspond with the records. This meant that some people might not have received some of their medicines. Staff attended medication training sessions but were not formally assessed. There was a varied programme of activities but residents did not have an opportunity to go out in the community. The safeguarding procedure did not provide adequate guidance for staff. Staff did not always notify CQC about significant events that occurred in the home. The induction training programme for new staff did not cover all of the common induction standards. The records that were kept about training were not up to date and did not provide information about the staff members training history. The home did not have an effective quality assurance system. The provider did not arrange for someone to undertake unannounced visits on their behalf, once the previous arrangement broke down. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 8 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.V375321.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 does not apply to this home. People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People could view the home and facilities before they moved in. Staff carried out a care needs assessment to see what help people would require, and to check that the home would be able to meet their needs. EVIDENCE: The registration certificate was displayed in the reception area. The home had developed two information booklets, a Statement of Purpose and a Service User Guide. These documents were displayed in some of the rooms that we visited. Some of the information in the documents such as the name of the manager was out of date. See recommendation 1. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 10 The arrangements for admitting new people into the home had improved. A new form had been developed for recording information about peoples support needs. The assessment form prompts staff to consider and record information about specific areas of need such as mobility, health issues, nutrition, continence, safety and behaviour. The form also includes information about bedtime routines and preferred times for getting up and going to bed. We examined three assessments, one was for a person that had lived in the home for several years, one was for a person that had lived in the home for six days and one was an emergency admission. Assessments were completed by senior staff and were undertaken before people moved into the home. The exception to this was the resident that required an emergency placement. The assessments that were completed on the new assessment form contained more detailed information about residents support needs. This information will help staff to prepare for admissions and meet people’s needs on admission to the home. People could visit the home to view the facilities and talk to staff or people that use the service. Most of the residents that we spoke with said they were too unwell to visit the home but said one of their relatives or a friend did this on their behalf. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were happy with the support they received in the home but the care records and the management of medicines suggest that this standard was not maintained consistently. Staff treated people with respect and showed concern for their health and welfare. EVIDENCE: We examined three sets of care records. The standard of record keeping was variable. Documents about similar issues such as falls and moving and handling were not always kept together. This made it difficult to locate information. Several new documents had been introduced in the period since the last inspection. Some of these documents were very good but they had led to some duplication of information. For instance some of the files included a care plan and a St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 12 document called ‘things that I would like you to help me with’. Some of the information in these documents was similar. The manager said she was planning to review all of the records and establish a standard set of documents. Care plans were easy to follow and some of the plans that we looked were designed to meet people’s individual needs and preferences. For instance one care plan provides important information about the type of foods that the resident liked and disliked and clear information about the support that the resident required throughout the day to eat and drink. We could see that staff followed the guidance in the plan. Some of the other plans that we looked at did not contain adequate detail or address all of the residents needs. For instance a male resident had a plan about the support that they required to wash and dress. The plan did not state if they required support to shave although it was clear that they would require assistance with this activity. Another resident was assessed to be at high risk of developing pressure sores but there was no information in the care plan about the action staff should take to protect their skin. One person had a history of falls and was assessed to be at risk of falling. There was no guidance in the care plan about the action that staff should take to reduce this risk. See requirement 1. Information about resident’s dietary needs had improved. A nutritional assessment tool was used to identify people that were at risk of becoming malnourished, residents were weighed regularly and care plans indicated if people required support to eat or drink. We observed staff supporting one person that had a poor appetite to eat and drink. The resident was offered alternative food as they did not want the main lunch time meal and was also prompted throughout the day to have regular drinks, food supplements and small snacks. We looked at the supply of medicines and medication charts for three residents. Staff kept good records about medicines that were received in the home. Although medication charts indicated that people usually received their medicines regularly and on time we identified discrepancies with the balance of some medicines. For example when we deducted the amount of medicine given to a resident from the amount received in the home we found there were more tablets than we expected. See requirement 2. Information that was written by hand on medication charts was checked and countersigned by a second member of staff. All medicines were in stock. As all of the medicines were in bottles or packets the trolley was full. This made it difficult to locate medicines. We discussed the advantages and disadvantages of using a monitored dosage system with the owner and manager of the home. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 13 The home had a cupboard in the office for medicines that require special storage arrangements. The manager was asked to check that the cupboard complies with legislation. See recommendation 2. Records that were kept about the receipt, use and disposal of controlled drugs were satisfactory. Medicines were administered by senior staff. Although staff completed medication training courses there was no evidence that they were assessed as competent to undertake the task. See requirement 3. Residents and relatives said staff were “friendly” and “helpful”. We observed staff communicating and reassuring residents, some of whom were anxious because they believed they had lost personal items or were worried about family members. All of the interactions that we observed between staff and residents were positive. Staff engaged residents in conversation and listened to their views. One relative asked a staff member if she could remain in the home during the lunch period to support her family member. Staff checked whether the other residents sitting at the table objected to this before they responded. Resident’s privacy and dignity was maintained. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The range and frequency of activities had improved but the home must ensure that there are sufficient staff available during the sessions to support residents. Relatives said they were able to visit at anytime and could spend as long as they liked with their family member. Residents were able to choose what they ate and were given time and support to eat, at their own pace. EVIDENCE: The activity programme includes a weekly exercise session that was facilitated by an external company and ‘one to one’ and group activity sessions that were organised by care staff. Records showed that there were regular opportunities to take part in activities in the home and that staff varied the content of the sessions. Some of the residents had taken part in bingo, sewing and craft activities and enjoyed manicures and aromatherapy sessions in recent weeks. We observed a quiz session in the lounge during the inspection. Staff provided clear instructions and encouragement and tried to involve all of the residents St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 15 that wanted to participate. The session was interrupted because staff had to attend to residents that requested assistance or were at risk. We were told that one of the kitchen staff had to leave early so the member of staff that would usually be available to attend to residents had to prepare supper. We saw some of the recent feedback that relatives provided about the service. Although relatives were satisfied with the care provided in the home a number of people said the home did not provide adequate occupation for residents. We have repeated the recommendation that made at the last inspection about appointing a dedicated activities coordinator. See recommendation 3. The home told us in their annual quality assurance assessment (AQAA) form that the activity programme included regular outings such as picnics and pub lunches. We did not see any evidence of this in the records that we looked at. One member of staff said the only improvement that the home needed to make was “days out” in the community. There were monthly entertainment sessions such as singers and musicians. Residents said they could decide where and how they spent their time. Most people chose to spend their time in the main lounge but some residents were seen going in and out of the garden and their rooms. One relative told us that their family member was able to go to the local shops until recently when they became unwell and another resident that chose not to take part in activities said they were not put under any pressure to join in. There was a resident’s and relatives meeting in April 2009 to introduce the new manager and to obtain feedback about the service. The minutes indicated that residents and relatives were able to ask questions and make suggestions. People said that they could visit the home at any time and could spend as long as they wanted in the home. We saw the owner of the home and staff welcoming relatives to the home and offering people refreshments. We observed staff serving lunch and supper in the dining room. The tables were nicely laid out in small groups so that people could sit with their friends. People told us that that they could choose what they ate and the records that we saw confirmed this. Food was nicely presented and looked and smelt appetising. We spoke to several residents during the lunch period, all of whom said the meals provided in the home were always good. Staff supported and encouraged people to eat, if necessary. The atmosphere was relaxed and people could eat at their own pace. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were familiar with the complaints procedure and knew who to speak to if they had concerns. There were procedures in place to protect the people that live in the home but they did not provide adequate guidance for staff. EVIDENCE: The complaints procedure was displayed in the hall way and information about the procedure was also included in the service user guide. Most of the visitors that we spoke to said they knew how to make a complaint and felt the home would investigate and address issues properly. One relative said the new manager “wants to know if things are not right”. We received one concern about the service in April 2009. We considered the concerns that were raised by the caller during the inspection. Although we could not find any evidence to support the claim we did discover that the home was not informing us about significant events such as allegations of misconduct and when residents were very unwell. See requirement 4. This issue relates to the period before the current manager was appointed. The home had not received any complaints during the past year but two concerns were investigated under local authority safeguarding procedures. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 17 The home had introduced a new policy about the acceptance of gifts and gave each staff member a copy of the policy to read and sign. In the period since the last inspection the home had organised safeguarding training sessions for staff and had revised and updated the homes safeguarding procedure. The procedure provides information for staff about different forms of abuse and states that allegations must be reported to a senior member of staff and the local authority. The procedure did not provide adequate guidance for staff about the action they should take to protect residents and did not state that CQC should be notified about allegations. For example the procedure did not state that staff should record what they were told or saw, that medical attention should be sought for the resident, if appropriate, that staff should inform the police and preserve any evidence if they believe a crime has been committed or that the alleged perpetrator should be suspended, if they are a member of staff. See requirement 5. All of the staff that we spoke to knew that they must report allegations, unexplained injuries and concerns to senior staff or the manager. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All of the areas used by residents looked homely and welcoming and were clean, tidy and comfortable. EVIDENCE: The home has a dedicated maintenance person. The building and grounds were well maintained and all of the equipment that we saw was in working order. We viewed two bedrooms on each floor. Residents said their rooms were comfortable and that there was space for some of their own furniture and belongings. Some of the rooms had an en suite toilet and shower and additional toilets and bathrooms were located on each floor. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 19 The ground floor bathroom was recently converted to a ‘walk in’ shower room. A new shower chair was purchased and the room was redecorated. The new shower room provides improved facilities and more choice for residents. The damaged flooring in the laundry room and a storeroom was replaced. The communal areas were pleasantly decorated and furnished. There were quiet areas where residents could sit if they wanted to read or spend time with their visitors. The television and music centre were switched on for part of the day or if residents wanted to watch specific programmes. The garden includes a patio area with seating, water feature, vegetable, herb and soft fruit patch and various garden ornaments which reflect light and sound. Some of the people that we spoke to said they derived a lot of pleasure from looking at or spending time in the garden. A high standard of cleanliness was maintained throughout the building. Relatives said the home was always clean, fresh and odour free and one person said the building feels “very homely”. Although the home is bigger than most of the residential properties in the road it still has the appearance of a family home. There were lots of well tendered plants and ornaments dotted around the building and the bedrooms were individually decorated. The local authority inspected the main kitchen in July 2008. The report indicated that the service had improved since the last visit. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a caring and competent team of staff. Recruitment practices had improved. This helps to ensure that people receive safe and suitable care. Induction training was provided for new staff but the session did not cover all of the common induction standards. EVIDENCE: The manager, a senior carer and two care workers were on duty when we arrived in the home. Staff carried out their work in a calm manner and responded promptly to requests for assistance. Some of the residents and relatives that we spoke to said staff were “exceptionally friendly”, “sensitive” and “caring”. The home had used some temporary staff to cover staff sickness or vacancies in recent months but this did not occur regularly. 60 of care staff had a National Vocational Qualification in Care (NVQ) at level two or above. This exceeds the standard set by the Department of Health. The application form for new staff looked dated and required applicants to provide some information that was not relevant to the post and could be considered unfair, such as how many children the person has. The form asked St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 21 the applicant to provide the details of two referees but the relationship of the person that they nominated was not always clear. This made it difficult to establish if one reference was from their last employer. See recommendation 4. We looked at the recruitment records for two members of staff. The files contained all of the required documents. References were checked to ensure that they were genuine. Criminal record bureau disclosures and protection of vulnerable adults (POVA) checks were completed for all staff and the home had developed a policy statement about employment of ex- offenders. We examined the homes disciplinary procedure. The procedure was easy to follow and provides detailed and up to date information for staff. Training records were disorganised. Although there was evidence of some training in staff files we were told that some of the staff had completed other sessions. It was not possible to see from the records when staff last completed mandatory training sessions such as health and safety and when they required an update. See recommendation 5. In the period since the last inspection some of the staff had attended moving and handling, fire safety, safeguarding, infection control and deprivation of liberty (DOLS) training sessions. The owner of the home had arranged some training such as dementia with a private training company but had to cancel the sessions because there was a lack of flexibility about the way the training was organised. Senior staff spent time with new employees discussing local policies, procedures and practices but the session did not cover all of the common induction standards. See recommendation 6. We received three comment cards from staff and spoke to three members of staff during the inspection. Staff were satisfied with the training and support that they received in the home. Relatives said staff had the right skills and experience to care for the people that live in the home. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The atmosphere in the home was open and supportive. There were good systems in place to safeguard resident’s money and to monitor health and safety issues. Some quality assurance work was taking place but this did not include monitoring visits. EVIDENCE: A new manager was appointed in April 2009, just prior to this inspection. The manager had experience of caring for older people and managed another home for older people when the registered manager was off duty. The manager St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 23 requested information about the registration process and had obtained an application form. The manager was not expected to undertake any care worker shifts. Staff and relatives said the new manager was approachable and supportive. The manager had only been in post for a short period but had already introduced some changes and knew that further improvements were required. The home had some systems in place for monitoring the quality of care and services provided in the home. Satisfaction surveys were sent to residents and relatives in April 2009 but the results were not collated and there was no evidence that any action was planed to address the issues that were raised. Senior staff carried out regular medication audits to check that staff were maintaining adequate records and following procedures. There had not been any unannounced visits to assess the conduct of the service since January 2009. As arrangements were put in place after the last inspection to address this issue, but subsequently broke down we have extended the timescale for meeting this requirement. See requirement 6. We were told that the home does not hold any personal money for residents except payment for hairdressing and chiropody services. Staff kept records about money or cheques that were held for this purpose and the record was signed by a staff member and the hairdresser once the payment was made. The home did not hold any valuable items for residents but there was some unclaimed jewellery. The manager was advised to ensure that records were kept about these items. See recommendation 7. The maintenance person carried out health and safety checks and completed routine repairs within the home and grounds. There were regular fire alarm tests and drills and fire safety equipment was inspected by a specialist company. The fire safety risk assessment was reviewed and updated in July 2008. Equipment such as hoists, assisted baths and the passenger lifts were serviced regularly. Gas, portable electric appliances and the mains electrical installation were inspected to ensure that they met safety standards. A letters was kept on file about compliance with the Water Supply regulations and the water tanks were cleaned and chlorinated at regular intervals. Staff completed an individual moving and handling assessment for each resident. Assessments provided clear guidance for staff about the number of staff and the type of equipment that was required to move people safely. We observed staff supporting people to walk and assisting people to transfer from a wheelchair into a more comfortable chair in the lounge. All of the transfers were carried out in a professional and safe manner and residents were told what they could do to assist staff. St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 24 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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 3 X X 3 X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X X 3 St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 25 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. 2. 3. Standard OP7 OP9 OP9 Regulation 15 13 13 Requirement Strategies to manage risk, must be developed and recorded in residents care plans. Systems must be put in place to ensure the safe administration of medicines. A formal system must be established to check that care staff are sufficiently competent in medication administration before they are allowed to give medicines. The procedure must be repeated at regular intervals and recorded in the care worker’s training file. The commission must be notified without delay about the events listed in regulation 37 of The Care Homes Regulations 2001. The home must develop a robust procedure for responding to suspicion or evidence of abuse or neglect. The owners of the home or another nominated person must visit the home once a month to assess the conduct of the service. The manager must be given a written report about the DS0000006785.V375321.R01.S.doc Timescale for action 17/09/09 17/09/09 17/09/09 4. OP18 13 17/09/09 5. OP18 13 01/10/09 6. OP33 26 01/10/09 St Margaret`s Ltd Version 5.2 Page 26 visit. Repeated requirement. The previous timescale of 14/08/08 was not met. 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 Information for residents and relatives such as the statement of purpose and service user guide should be reviewed and updated regularly. This will ensure that people have access to accurate and up to date information about the service. Confirmation should be sought from the manufacturer that the current CD cupboard complies with the Misuse of Drugs Act. Serious consideration should be given to recruiting a dedicated activities coordinator. Recruitment records should be reviewed and updated. A staff training matrix should be developed and maintained. The induction training programme for new staff should cover all of the common induction standards. Records should be kept about valuable items that are found in the home. 2. 3. 4. 5. 6. 7. OP9 OP12 OP29 OP30 OP30 OP35 St Margaret`s Ltd DS0000006785.V375321.R01.S.doc Version 5.2 Page 27 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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