Inspection on 08/05/08 for St Margaret`s Ltd

This inspection was carried out on 8th May 2008.

CSCI 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 05/05/09

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 28/09/2008.

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 8th May 2008 09:25 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.V362825.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.V362825.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 (0), Old age, not falling within any registration, with number other category (0) of places St Margaret`s Ltd DS0000006785.V362825.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 30th May 2007 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 with the Commission for Social Care Inspection (CSCI) to provide personal care and accommodation for 22 older people with dementia. St Margarets 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 is located in a large detached two-storey house, with a purpose built extension and a passenger lift. 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 single toilets. 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. The current fees range from £479.00 to £650 per week (this information was supplied to the commission on 08/05/08). Residents are responsible for purchasing personal items and services such as toiletries, hairdressing and newspapers from their own funds. St Margaret`s Ltd DS0000006785.V362825.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 2008. The inspector spent fifteen hours in the home. In preparation for the inspection we read all of the information that we had received about the service since the last inspection such as complaints, notifications and the Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self- assessment form that homes complete once a year. The AQAA provides information about how the home is meeting the national minimum standards and some numerical information about the service. During the inspection we assessed all of the key standards and obtained some additional information about how the service protects the people that live in the home. We did this by obtaining both written and verbal feedback from people that lived, worked in and visited the home and by examining various records. We also observed staff communicating with residents and visitors and supporting people to eat and drink and take their medicines. A staff member showed us around the home and we were invited to see three resident’s bedrooms. There were 21 people living in the home at the time of the inspection and one resident was in hospital. What the service does well: The home provides written information about the facilities and services that it offers. People could visit and spend time in the home before making a decision to move in. Arrangements were made for people to see their GP or other health care professionals if necessary. Health care professionals said that staff were “kind”, “caring” and “helpful”. Medication records were good. This promotes resident’s safety and wellbeing. The home was safe, clean and comfortable. People could bring their own possessions with them and could rearrange their room to suit their needs. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 6 Staff addressed people in a professional but caring manner and were discreet when dealing with sensitive issues. Relatives could visit at anytime and could access all of the communal areas or spend time with their family member in the privacy of their room. People had an opportunity to socialise during mealtimes and were given adequate assistance and time to eat. People said they were asked what they wanted to eat and usually liked the food that was provided in the home. Most of the staff that worked in the home had a recognised care qualification. Equipment was serviced regularly and fire safety arrangements were good. What has improved since the last inspection? What they could do better: Some records were not dated, signed or properly completed and could not be found. The manager must ensure that these issues are addressed. One member of staff was responsible for transferring resident information onto new documentation. This needs to be completed as soon as possible and requires a team effort. Staff identified health needs such as poor nutrition, but St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 7 it was not always clear from the records if adequate steps were being taken to monitor and address concerns. Some activities were taking place but a number of residents and relatives said there was not enough for people to do. The doors in the corridors all looked very similar. The home should provide signs to help people with dementia to locate specific areas such as the toilets. The flooring in the laundry room should be replaced as it was split and could harbour dirt. The domestic style bath, in the ground floor bathroom was not used, as residents could not get in or out of it. Although the home had an adult protection procedure it did not provide adequate guidance for staff and staff did not read it. The home must take greater care when recruiting new staff to ensure that references are independent, information is genuine and that risks to residents are properly considered. The home must be able to show why staff were selected and demonstrate that all applicants were treated fairly. Training for new staff should cover all of the common induction standards. Some staff had attended a formal supervision session but this did not take place regularly and did not include all members of the team. Senior staff had not received supervision training. The home did not have an effective quality assurance system. The home should be identifying and addressing the issues that we found during this inspection, during audits and monitoring visits. The fire risk assessment was not reviewed regularly and moving and handling equipment checks were overdue. Information about hazardous substances was kept in the home but was rather complex. The manager could use some of this information to complete COSHH assessments. 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.V362825.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.V362825.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. (Standard 6 does not apply to this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were given information about the service and were able to visit and spend time in the home before they decided to move in. There were lots of interesting areas to explore in the home and grounds, but the lack of signage made it difficult for residents with dementia to identify different rooms. EVIDENCE: The registration certificate and a valid public liability insurance certificate were displayed in the reception area. People said they received adequate information about the service before they moved into the home. A number of people that we spoke with said they spent time in the home before they made a decision to move in or were told about the home by relatives that visited the service. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 10 We asked to see the assessments that were carried out for two new residents that had moved into the home in recent weeks. The local authority had supplied a comprehensive assessment and care plan in respect of one resident but the manager could not locate the information that she said she had recorded about the other resident needs, when they visited the home. See requirement 1. The home varied its registration category in 2007 and can now admit people with dementia. The Service User Guide, an information booklet about the service, was recently updated to reflect this change. Work was in progress to provide more stimulation for people with dementia, particularly in the garden. There were no signs on the toilet and bathroom doors. This would help people with dementia to locate these rooms. The manager said work was planned to address this issue. See recommendation 1. Residents were able to move about the home as they pleased and there were lots of things to look at and areas where they could rest along the way. St Margaret`s Ltd DS0000006785.V362825.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Health care issues were identified by staff but were not always properly monitored or addressed. This could compromise people’s health, safety and wellbeing. People received their medicines on time and were supported by staff to take their medicines regularly. People said staff treated them with respect and maintained their privacy and dignity. EVIDENCE: One staff member was responsible for updating the care plans and risk assessments and for transferring the existing information over to new documentation. This is a lengthy piece of work for one person and is likely to take some time to complete. See recommendation 2. The new documentation will provide much more detailed information about people’s individual needs, strengths and preferences such as ‘things that I can do for myself’, ‘things that I need help with’, the person’s preferred name, who they St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 12 want to be involved in their care and information about ‘My life before you knew me’. We examined the care files for two residents that had recently moved into the home and one for a person that had lived in the home for several months. The first file included some useful information about the person’s social and physical needs and wishes. This resident was known to be at risk of falls and told us that they had fallen in the toilet just a matter of days before the inspection. There was a care plan about maintaining the resident’s safety and guidance for staff about what they should do if the person did fall. Some of the information about the persons nutritional needs was confusing, for instance the nutritional assessment stated ‘usual appetite-finishes most meals’ but the pressure sore risk assessment (waterlow) and the nutritional care plan indicated the person had a poor appetite. The care plan provided information about the persons preferred diet but did not state if staff should be doing anything else, such as monitoring the person’s weight or food intake. The resident was also assessed to be at high risk of developing pressure sores but there was no plan to show what action staff should take to minimise the risk of the person developing a sore. The second file included more personal information about the resident such as information about what the resident liked to wear, but as with the first file did not state if staff were taking any action to address concerns that were recorded about the residents weight and appetite. See requirement 2. Residents were weighed regularly but this seemed to be done routinely every month and there was no evidence that people that had a poor appetite were monitored more frequently. The third file was for a resident that had only lived in the home for a couple of days. Staff had completed some assessments but there was no care plan for this person. See requirement 1. There was a specific form for recording the resident or relative’s agreement to the proposed care plan but this document was not always completed and some of the records that we saw were not dated or signed. The manager could not find some of the daily care notes for two residents. Three health care professionals commented about the homes record keeping practices. One person said “assessments were slightly ad hoc” at times, another person said the home needs to improve its filing systems and one person said paperwork was not always made available for them during their visits. See requirement 1. We spoke with two residents during the inspection and received written comments from six resident’s, five of which were assisted by relatives to complete a comment card and a staff member supported one person. Most St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 13 people said they usually received the medical support and care that they needed. We spoke with one health care professional that was visiting the home and received written comments from four other health care professionals that were in regular contact with the home. Health care professionals told us that staff usually sought advice about health care issues such as sores and injuries and referred appropriate issues to their team. Health care professionals said that staff usually followed their advice or instructions and were usually able to meet people’s health care needs. One person told us that they thought the people that lived in the home received good care. Most relatives were satisfied with the support and care that their family member received and said they were told about important issues such as hospital visits and accidents. We examined two medication charts. Good records were kept about medicines that were received in the home and were given to residents. Staff recorded an explanation on the chart when people refused to take their medicines and when a variable dose of medicine was prescribed, such as 1 to 2 tablets the actual number of tablets that people were given was recorded. Most of the information that was recorded on medication charts was printed but when staff information that was hand written was checked and countersigned by a second member of staff to reduce the risk of errors. Medicines were stored securely but the temperature of the medicine refrigerator was not monitored. See recommendation 3. A risk assessment was completed for one person that was administering their own eye drops. Staff knocked on people’s doors before entering and addressed people in a respectful manner. A staff member promptly intervened when one resident became physically and verbally aggressive towards another resident. Attempts were made to distract the resident but when this did not work the resident was escorted to another area, to calm down. St Margaret`s Ltd DS0000006785.V362825.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity programme did not meet people’s individual needs and expectations. Relatives said they could visit at anytime and were always welcomed by staff. People said they could choose what they ate and usually enjoyed their meals. EVIDENCE: There was evidence of some activities taking place in the home but it was clear from the comments that we received that there were some concerns about the provision and frequency of activities in the home. One resident described activities, as “spasmodic” and said information in the homes information booklet about activities and outings was not accurate. Another resident said, “It would be nice to have some extra activities”. Relatives and health care professionals also provided some feedback about activities. One person said that it would be nice for residents to have more stimulation such as craftwork and colouring and another person said they had St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 15 noticed that staff, “were not particularly pro-active in planning social activities”. The manager said the home was trying to recruit a dedicated member of staff to undertake activities with residents and had recently arranged for care staff to spend some ‘one to one’ time with residents. One resident said care staff had some good ideas such as making Christmas decorations but their ideas were not always carried through. A dedicated activities person would be able to devote all of their efforts and time to activities. See recommendation 4. The current programme of activities includes a weekly exercise session that is facilitated by an external company and ‘one to one’ and group activity sessions that were organised by care staff. There was some entertainment from time to time but this did not happen regularly. There was no evidence of any recent outings in any of the records that we saw. The manager was starting to develop an individual reminiscence box for each resident, with support from relatives. The contents of the box will provide topics of conversation for staff and residents and will help residents to remember their past lives. Residents and relatives used the quiet lounge at the front of the building to listen to music and relax. Some sensory lighting had been purchased for this room and a large fish tank provides additional interest. We spoke with two sets of relatives during the inspection. They told us that they could visit the home at anytime and said staff were always pleasant and helpful. Residents said they were able to choose what they wanted to eat from the menu and could decide when they wanted to go to bed or get up. Some people said they liked to spend time alone in their room and did not want to go to the lounge or take part in activities. We observed lunch being served on the second day of the inspection. The dining tables were nicely laid out in small groups and people were able to sit with their friends. People told us that that they could chose what they wanted to eat from the menu and were offered alternatives if they did not like the food provided. One relative said staff had gone out of their way to provide different foods for her family member, who had a poor appetite and required a special diet. There was mixed feedback about the food provided in the home. Two relatives said that meals were “excellent” and “food seems to be of a good standard”. Two other relatives stated that “more fresh food” and “a better diet” was required. Most of the people that we spoke with during the inspection said they enjoyed their lunch. St Margaret`s Ltd DS0000006785.V362825.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available 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 lived in the home but they lacked detail in parts and staff did not read them. EVIDENCE: The complaints procedure was displayed. The procedure stated whom people should contact if they had any concerns and how long it would take the service to investigate and respond to their complaint. The procedure also stated that people could contact other people in the company or other organisations if they were not satisfied with the manager’s response. Residents said they would speak to a member of staff or their relatives if they wanted to make a complaint. The manager said the home had not received any formal complaints in the previous twelve months. Health care professionals told us that concerns were usually dealt with appropriately and “sorted out straight away”. 80 of relatives said they knew how to make a complaint but two people said the home had not always responded appropriately to their concerns. As there were no records of any St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 17 concerns or complaints in the home we could not assess this issue in more detail. The manager should ensure that all concerns, however small, are logged. We spoke to three staff about how the home protected the people that used the service. Most of the staff that we spoke with knew what abuse was and were able to give examples of physical and mental abuse. Most of the staff that we spoke with had limited knowledge about other forms of abuse and about the homes safeguarding and whistle blowing procedures. Most of the staff that worked in the home had attended abuse awareness training. The home had a safeguarding procedure. Although staff knew that the procedure existed none of the staff that we spoke with had read it. The procedure had been updated since the last inspection to include notifying social services about allegations of abuse but did not make any reference to the roles played by other organisations such as the police and CSCI. Some of the wording in the procedure was rather vague for instance one part stated that staff should “deal with the matter accordingly”. See recommendation 5. St Margaret`s Ltd DS0000006785.V362825.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 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. Parts of the home had been redecorated and refurbished and the garden project was almost complete. All areas were clean, comfortable and welcoming. EVIDENCE: The home employed a part time maintenance person. This person was responsible for undertaking repairs, carrying out health and safety checks and ensured that the garden and grounds were safe and tidy. The building was well maintained overall but two issues were discussed with the deputy manager during the tour of the home. The hand drier in the toilet opposite the small lounge was broken and the flooring in the laundry was split. See recommendation 6. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 19 All areas were clean, tidy and free from unpleasant odours and residents said the home was always fresh and clean. In the period since the last inspection the lounge had been redecorated and new dining and lounge furniture was purchased. This made the room look cleaner and more inviting. Staff should consider rearranging some of the chairs into small groups to promote social interaction and to provide a more homely atmosphere. A significant amount of work had been undertaken to improve the layout of the garden and to provide more stimulation for residents with dementia. Some additional seating had been provided in the shaded parts of the garden, a large water feature had been installed and there were some new paved areas to help people to gain access to different areas. New lights were fitted under the water feature and sensory garden ornaments such as wind chimes and sun catchers were placed under the trees. Residents and relatives said that, “the garden was coming along nicely” and told us that they were looking forward to the fish arriving. Bedrooms were spacious and residents were able to bring some of their own furniture and belongings into the home if they wished. One of the shared bedrooms was recently changed into a single occupancy bedroom and another room was converted into a bedroom with en suite facilities. This work was carried out in consultation with the commission and a site visit was carried out in July 2007 to check that the new room was ‘fit for use’. The new bedroom was spacious and bright. One of the bathrooms has a domestic style bath that we were told most of the people living in the home could not use. The owner of the home said they had made some enquiries about converting the bathroom into a shower room and other options were being explored. See requirement 3. A local environmental health officer inspected the kitchen in January 2008. A number of requirements and recommendations were made about record keeping, training and cleanliness issues. The manager said all of these issues were addressed. St Margaret`s Ltd DS0000006785.V362825.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were adequate staff to meet people’s needs but as the home starts to admit more people with dementia the current staffing levels will need to be reviewed. Recruitment practices were good overall but some information was not checked and there were no records to show why applicants were appointed. New staff received induction training but this did not cover all of the common induction standards. EVIDENCE: We looked at the duty roster for the period 05/05/08-18/05/08. The duty roster was easy to read and follow. There were usually three or four care staff on duty on the morning shift, three care staff on the afternoon shift and two waking night staff. A senior member of staff led all shifts. Five members of staff expressed concerns about staffing levels but most residents said staff were usually available when they needed help. Staffing levels will need to be reviewed as the home starts to admit more people with dementia. Staff carried out their work in a professional but friendly manner and responded promptly to requests for assistance. Residents, relatives and health care professionals told us that staff were “very caring”, “usually very helpful”, “kind and caring” and friendly and pleasant”. 83 of residents said that staff St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 21 listened to what they had to say and one person said, “You can ask them anything”. 77 of care staff had a National Vocational Qualification in Care (NVQ) and one member of staff was registered to complete this programme. We looked at three staff recruitment files. Although the files included all of the documents and checks that were required there was no evidence that references that were not company stamped or on headed paper were verified to ensure that they were genuine. This issue was identified at the previous inspection but was not addressed. Failure to address this issue could compromise resident’s safety and might result in enforcement action. Applicants were asked to provide two referees but did not have to state the referee’s job title or how they knew the person. This made it difficult to establish if the reference was a personal or professional reference. One reference was from an applicant’s relative. See requirement 4. Criminal record bureau checks were completed for all staff but the home did not have a written policy about the employment of ex- offenders. A sample policy is available on the Criminal Records Bureau website. See recommendation 7. There was no written evidence that staff were formally interviewed before they were appointed. The manager said that she did bring people in for “a chat” and the owner also spent time with prospective employees. Because records were not maintained about interviews it was not possible to establish if all applicants were asked the same questions and were treated fairly. See recommendation 8. We examined the induction training records for three staff. All of the staff had received some induction training but some topics were not covered and one induction booklet was not signed. The induction training programme did not cover the common induction standards. See recommendation 9. Since the last inspection some of the staff had attended food hygiene, medication awareness, health and safety, moving and handling and safeguarding adults training sessions. There were individual training records for each member of staff but the records were not completely up to date. The manager should develop a training matrix so that she can see at a glance when mandatory training sessions are due and then use this information when preparing the homes annual training programme. See recommendation 10. Six members of staff completed a comment card about the home and we spoke with three members of staff during the inspection. Staff were satisfied with training arrangements and said the sessions that they attended helped them to meet residents needs. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 22 80 of relatives and 100 of health care professionals said that staff usually had the right skills and experience to meet people’s needs. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 23 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): 31, 32, 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. The manager must be allocated adequate time to fulfil her role and meet the National Minimum Standards. The homes quality assurance system should be reviewed and updated to identify and address the issues highlighted in this report. The building was well maintained and safety issues were usually well managed. EVIDENCE: The manager said that she had 30 hours management time, each week and spent one shift ‘on the floor’ each week. We checked the duty roster for a two- week period. The manager did not have any days off and undertook nine care/cooking shifts and seven management shifts during this period. This St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 24 might explain why some management issues such as staff supervision, care planning and record keeping were not properly monitored. See requirement 5. The manager of the home will retire in 2008. We discussed the process for registering a new manager with the owner of the home and provided advice about the qualifications and experience that the new manager should have. Staff and relatives said the manager was approachable and supportive. Most staff said they met the manager regularly to discuss their work and felt supported. The home had recently implemented a new quality assurance system. The process involved staff obtaining feedback from residents about specific topics such as food, the laundry service and activities. The findings were difficult to follow in parts, as various topics were surveyed at the same time and in some cases the sample size was so small that it would be difficult to decide if this was one persons opinion or represented the views of the people that lived in the home. The results were not collated and there was no action plan to show if the home had used the information that they had collected to improve the service. Feedback from residents is extremely valuable but staff may find that they have difficulty over time getting reliable feedback, as more people with dementia are admitted to the home. It is recommended that the home supplement the current system with other tools such as audits and satisfaction surveys. See recommendation 11. The owners of the home are required to complete monthly, unannounced visits to check that the service is being properly managed. There was no evidence that these visits had taken place since August 2007. See requirement 6. We were told that the home does not hold any personal money or valuable items for residents but some residents were able to look after their own money and some relatives gave staff personal cheques to pass onto the hairdresser. Staff should consider keeping a list or obtaining a receipt from the hairdresser to confirm who she has seen as it would be difficult to prove who had seen the hairdresser after the event. Two out of the three staff that we spoke with had not received any formal supervision. The records that we looked at indicated that some staff had an opportunity to discuss their work and training needs during a supervision session. Although some progress had been made with this requirement further work is required to meet the required standard. See recommendation 12. Staff that were responsible for supervising other staff members had not received any training for this role. See requirement 7. Hazardous substances were stored securely and data sheets were kept about the use and risks associated with these substances. Some of the information St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 25 on the data sheets was quite old (2004) and some of the language used was rather technical. The manager should complete easy to read COSHH assessments for all of the hazardous substances that are used in the home. See recommendation 13. Staff recorded information about accidents and incidents that occurred in the home on a specific form. We examined some of the forms for recent accidents that had occurred in the home. Most of the forms were about falls and trips. A small number of people required hospital treatment following a fall and some residents were referred to the falls clinic because of frequent, unexplained falls. It was not always clear on the form if a staff member had witnessed the event or if the information recorded was the residents account of what had happened. The manager should ensure that staff only record what they see, hear or are told. See recommendation 14. A fire risk assessment was completed in 2006. This document should be reviewed at regular intervals to ensure that information is still relevant and up to date. See recommendation 15. The fire alarm was usually tested once a week but the tests had lapsed in recent weeks. The manager said that she would ensure that the fire alarm was tested at regular intervals. A specialist company inspected fire safety equipment such as the emergency lighting and fire alarm system and fire extinguishers. All of the fire exits were clear. There were monthly drills to check that staff knew what to do in an emergency. The London Fire and Emergency Planning Authority (LFPA) visited the home in March 2008 and found that fire safety arrangements were satisfactory. Equipment was serviced regularly to ensure that it was working properly and safe for use. The only exception to this was lifting equipment such as hoists, which had not been serviced since August 2007. See requirement 8. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 26 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 2 2 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 4 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X N/A 2 X 3 St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 27 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. Standard OP7 OP7 Regulation 17 12 Requirement All records must be up to date, named, signed, dated and stored securely. Staff must take appropriate action to meet people’s nutritional needs. Any action taken by staff must be recorded in the persons care plan. The ground floor bathroom must be adapted to meet the needs of residents. Repeated requirement. The previous timescale of 20/07/08 was not met. 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. Repeated requirement. The previous timescale of 10/01/08 was not met. The manager must be allocated adequate time to undertake her responsibilities and fulfil her role. The owners of the home or another nominated person must visit the home once a month and prepare a written report about DS0000006785.V362825.R01.S.doc Timescale for action 14/08/08 14/08/08 3. OP21 23 30/12/08 4. OP29 19 14/08/08 5. 6. OP31 OP33 12 26 14/08/08 14/08/08 St Margaret`s Ltd Version 5.2 Page 28 7. OP36 18 the conduct of the service. A copy of the report must be supplied to the manager. Staff that are responsible for supervising other members of staff must receive appropriate training for this role. 25/09/08 8. OP38 13 Arrangements must be put in place to ensure that moving and handling equipment is inspected at regular intervals. 14/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP4 OP7 Good Practice Recommendations Appropriate signs should be used in the building to assist residents with dementia to locate specific areas and to navigate their way around the building. All of the staff should be involved with the transfer of information from the existing records to new documentation. The temperature in the medication refrigerator should be monitored to ensure that it is suitable for the storage of medicines. Serious consideration should be given to recruiting a dedicated activities coordinator. The safeguarding procedure should be reviewed and updated to include the role and contact details for referrals, for organisations such as social services, the police and CSCI. Staff should read and familiarise themselves with the procedure. The split floor covering in the laundry room should be replaced. The home should develop a written policy about the employment of ex- offenders. Staff interviews should be recorded. This will demonstrate that all candidates are treated the same. DS0000006785.V362825.R01.S.doc Version 5.2 Page 29 3. 4. 5. OP9 OP12 OP18 6. 7. 8. OP19 OP29 OP29 St Margaret`s Ltd 9. 10. 11. OP30 OP30 OP33 12. 13. 14. 15. OP36 OP38 OP38 OP38 The induction training programme for new staff should cover all of the common induction standards. A staff training matrix should be developed and maintained. It is recommended that other tools such as audits and satisfaction surveys are used to monitor compliance with the homes policies and procedures and the National Minimum Standards. Care staff should receive formal supervision six times a year. COSHH assessments should be completed for substances that are hazardous to health. Accident records should provide clear information about what staff saw, heard and found or what the resident said happened. The fire safety risk assessment should be reviewed and updated regularly. St Margaret`s Ltd DS0000006785.V362825.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V362825.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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