Inspection on 09/12/04 for St Margaret`s Ltd

Care Home For Older PeopleSt Margaret`s Ltd3 - 5 Priestland`s Park Road Sidcup Kent DA15 7HRUnannounced Inspection9th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment St Margaret`s Ltd Address 3 - 5 Priestland`s Park Road, Sidcup, Kent, DA15 7HR Email address Name of registered provider(s)/company (if applicable) Mr Al-Naseer Hudda Name of registered manager (if applicable) Mrs Linda Masher Type of registration Care Home No. of places registered (if applicable) 22 Tel No: 020 8300 2745 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (22) Registration number G010000202 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 23/6/04 If Yes refer to Part CSt Margaret`s LtdPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 39th December 2004 10:00 am Ms Pauline LambeID Code096108Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionAngela WatersSt Margaret`s LtdPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementSt Margaret`s LtdPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of St Margaret`s Ltd. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.St Margaret`s LtdPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. St. Margarets is privately owned by Mr and Mrs Hudda and has been registered since 1971. The home is registered to provide care and accommodation for 22 older people. The Home is a large detached two-storey property, which includes a purpose built extension. A lift is available for the residents. St Margarets is located in a residential area close to transport and shops. There are three double bedrooms and sixteen single bedrooms, fourteen of which have en suite facilities. There are two bathrooms and three other WCs. A small lounge is situated at the front of the building in addition to a large lounge/dining room, which looks onto the attractive garden at the rear of the property. Residents have access to health care services via the local GP practice.St Margaret`s LtdPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) At the time of this unannounced inspection twenty-two service users were in residence and a senior carer was in charge. The inspection included talking to service users, relatives and staff. Inspecting records, safety systems and the environment. Service users spoke highly of the care provided and their satisfaction with meals, activities provided and their environment. Three relatives were seen and gave positive feedback on the standard of care provided. Not all standards were assessed on this occasion. The home was clean, tidy and free of odours and nicely decorated for Christmas. Staff were observed interacting appropriately with service users. Several service users had a manicure and their hair done in preparation for the planned Christmas party. Some service users said they had made new friends since admission and were satisfied with their lifestyle. Serious concerns were identified in relation to medication management. An immediate requirement was issued in relation to medication management. This was complied with by the timescale set. The Commission Pharmacist undertook a separate inspection on 13th December 2004 and the main findings of that inspection have been included in the body of this report. A full copy of the pharmacist inspection report was sent to the home. Concerns were identified in relation to care plans. These were scanty, did not reflect service user needs or show how identified needs were being met. Risk assessments were also scanty and must be improved. These concerns have been dealt with under the relevant standards The home manager was present during the latter part of the inspection. The inspector thanks all who assisted with the inspection. Choice of Home (standards 1 ­ 6) One standard was almost met, one did not apply and four were not assessed. As no changes had been made many standards in this section were not inspected on this occasion. Standard 6 did not apply to the home. A requirement was made in relation to standard 4. Health and Personal Care (standards 7 ­ 11) One standard was met, two were not met and two not assessed. Serious concerns were identified in relation to medication management. The Commission Pharmacist undertook a separate inspection of medication and the findings of that inspection have been incorporated into this report. Concerns were also identified in relation to care planning. These issues have been address under the individual standards and requirements were made where needed. The commission will monitor compliance with requirements.Daily Life and Social Activities (standards 12 ­ 15) One standard was met, one almost met and two not assessed. St Margaret`s Ltd Page 6 From the evidence provided and comments made by service users they were happy with how they lived their lives. Several service users said there were adequate activities provided and that they were happy with the quality of meals provided. Complaints and Protection (standards 16 ­ 18) One standard was met, one almost met and one not assessed. From the evidence provided systems were in place for the protection of service users. However the registered person should review the homes policies and procedures to ensure these are relevant to the home and the service provided. A copy of Bexley Social Services Adult Protection Procedures should be available to staff. Environment (standards 19 ­ 26) Six standards were met, one almost met and one not assessed. The standard not assessed was met at the last inspection. The home was generally clean and tidy and nicely decorated for Christmas. Service users said they were satisfied with their environment and visitors said they liked the fact that there were no unpleasant smells noted in the home. Requirements and recommendations were made in relation to decoration and repairs. Staffing (standards 27 ­ 30) One standard was met and three not assessed. The home maintained staffing levels as agreed prior to the introduction of the National Minimum Standards. Staff who spoke to the inspector said they were satisfied with their working and management systems. They said they had access to training relevant to their roles. Management and Administration (standards 31 ­ 38) Two standards were met, one almost met and five not assessed. From the evidence provided and the standards assessed the home was staffed to meet the needs of the service users and adequate safety systems were in place.St Margaret`s LtdPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Please see statutory requirements from this inspection.Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)St Margaret`s LtdPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The Registered Person must confirm in wiring to service users the time of admission that having regard to assessment the home is suitable for the purpose of meeting their needs in respect of their health and welfare. The Registered Person must prepare a written care plan, in consultation with the service user or their representative, as to how a service users needs are to be met in respect of their health and welfare. As most service users required up to date care plans a timescale was agreed with the manager.114OP431/1/05215OP76/5/05St Margaret`s LtdPage 9 The Registered Person must make suitable arrangements for the safe storage, receipt, disposal and administration of medicines brought into the home. Policies and procedures must be in place for ordering, receiving, storing, administering and returning medicines, self administration of medicines, supply of medicines for day leave and homely remedies. Records of receipt of medications must include the date of receipt. The home must keep a complete list of all currently prescribed medication for each service user, including when required medicines. Administration records must allow the recording of when required medicines and the time of administration. Administration records must be made after each service user has been observed taking their medication. If a medication dose is not given or taken then a non-administration code must be recorded. Medicines must not be re-dispensed into other containers in the home. Foil strips must not be taken out of the original labelled containers. If medicines are received (including when required medicines) that are not completely labelled with directions including a dose and frequency they must be returned to the pharmacy for clarification with the prescriber and relabelled. Medicines must not be handled during the administration process. Sufficient medicines cups must be available for each resident receiving medication. Internal and external medicines must be stored separately. 10/6/0511/2/05313OP911/2/0511/2/0510/12/04St Margaret`s LtdPage 10 413OP9The Registered person must ensure staff receive updated training on medicines handling and management. Staff must receive training on administration of oxygen. The Registered Person must ensure there is a formal system in place for the regular review of service users medication. An immediate requirement was left for the registered person in relation to the illegal practice of staff re-dispensing medications. The registered person was required to get a new supply of medications or to arrange for the supplying pharmacist to visit the home and check that the medications in the containers were those he dispensed. Timescale for compliance was by 12 noon on 10/12/04. The Commission received written confirmation that the pharmacist had visited and checked medications by the timescale set. The Registered Person must ensure all parts of the home are reasonably well decorated. A maintenance and refurbishment programme must be in place.10/6/05513OP910/6/05613OP910/12/04723OP2431/2/05826OP33The Registered Person must ensure visits are made to the home as required by regulation 31/1/05 26 and reports sent to the Commission. (Timescale of 5/9/04 was not met)St Margaret`s LtdPage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The Registered Person should have a cleaning schedule for the kitchen and should check with environmental health as to the need to have a fly mesh fitted to the kitchen window. The Registered Person is strongly recommended to review the homes policies and procedures to ensure they are relevant to the home. The Registered Person should ensure individual accommodation is fitted and furnished to meet this standard or that furnishing is agreed with the service user. The Registered Person should undertake a risk assessment in relation to windows above the ground floor. These open at the top only but did not have restricted openings. The risk assessment should address any risk these pose to service users.1OP152OP183OP244OP25* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.St Margaret`s LtdPage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO NO YES YES YES NO NO YES YES YES NO YES YES NO NO NO YES NO YES 7 3 X NO NO YES YES X X 9/12/04 10:00 7St Margaret`s LtdPage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.St Margaret`s LtdPage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/Evidence This standard was not assessed.YES Standard met? 0St Margaret`s LtdPage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? Prior to admission a copy of the care managers assessment was obtained. There was no formal record of a pre-admission assessment being undertaken by the home staff. The manager said she met prospective service users but did not record her assessment. The manager did not write to service users prior to admission, confirming the home could meet their assessed needs. Requirement 1. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed.St Margaret`s LtdPage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard did not apply to the home.Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 1 Key findings/Evidence Standard met? There was evidence seen in service users records of care manager assessments. Care plans were scanty and not reflective of service users needs. Care plans must be in place showing how needs are to be met and service users must be consulted when preparing care plans. The daily evaluation records did not reflect how care needs were met. The manager, deputy manager and inspector discussed care planning and the need to have these in place. Requirement 2.St Margaret`s LtdPage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 3 03 Key findings/Evidence Standard met? Records of all accidents were kept. Since the last inspection twenty eight accidents were recorded. This resulted in three service users attending A&E. All service users were registered with a G.P. The inspector was told that service users were supported to have regular checks in relation to dental, optical and chiropody care. Specialist services were obtained through G.P referral. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 1 Key findings/Evidence Standard Met? Medications were stored in a locked metal trolley in the managers office. Serious concerns were identified in relation to medication management. Staff were redispensing medicines dispensed by the supplying pharmacist. This practice is illegal and must cease with immediate effect. In view of these concerns identified the Commissions Pharmacist undertook a separate inspection on 13th December 2004. The requirements made from the Pharmacist inspection have been included in this report. A copy of the report has been sent to the home manager and registered person. An immediate requirement was left in relation to medication management and this was complied with by the timescale set. The inspector agreed to send the manager a copy of the British Pharmaceutical Guideline to enable her to update the medication policies and procedures. This was done following the inspection. Requirements: One immediate requirement and requirements 3,4,5 and 6.St Margaret`s LtdPage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed.St Margaret`s LtdPage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The inspector had the opportunity to talk to three visitors to the home. They said they could visit whenever they wished. Service users supported this comment. Service users could greet visitors in their bedrooms, the quiet lounge or the main lounge.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed. However it was noted that the inspection report displayed in the front hall was dated 2002. The most recent inspection report should be made available to service users and others.St Margaret`s LtdPage 20 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The manager and chef prepared the menus. These were changed twice a year and were prepared on a four weekly cycle. Menus seen were varied and included a choice of meal. Service users said they could have three cooked meals a day if they wished. Service users said they enjoyed their meals and if there was nothing on the menu that they liked they could have an alternative. The inspector observed lunch being served. This was done in a calm and organised manner. Assistance was offered to service users as needed and staff encouraged service users to enjoy their meal. The kitchen was clean and tidy. Night staff took responsibility for a lot of the cleaning in the kitchen. There was no cleaning schedule in place. There was no fly screen on the window. Records were kept of fridge, freezer and food temperatures. It was evident there was a good supply of fresh, frozen and dry foods. Recommendation 1.St Margaret`s LtdPage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard was not assessed. X X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Service users said they were involved with how their care needs were met and that they choose how to present. This was not reflected in their care plans but from information provided seemed to be done on a verbal basis with staff. A hairdresser visited weekly and service users had the choice whether to attend or not. Service users also said they could vote if they wished.St Margaret`s LtdPage 22 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 02 Key findings/Evidence Standard met? The home had policies and procedures however these were not all relevant to the home. Staff displayed their understanding of adult protection and what action to take if this was alleged or suspected. There had been no such allegations since the last inspection. Staff training in relation to adult protection was not assessed on this occasion. Recommendation 2.St Margaret`s LtdPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? Communal space consisted of a large lounge/diner and a separate quiet lounge. A well maintained rear garden with seating was provided. Service users said they enjoyed sitting in the garden when the weather was good. Lighting, furnishings and fittings were domestic in character. The home did not provide intermediate care.St Margaret`s LtdPage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? The home had adequate bathing and toilet facilities. These facilities had appropriate locks fitted to ensure service user privacy. Bathrooms were clean and tidy, hot water temperatures checked were within safe limits and records were kept of bath temperatures. In the last inspection reference was made to the need to have an assisted bath on the ground floor. The manager said this had not been provided and in her opinion was not required. This situation will be reviewed again at the next inspection.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The home had not been assessed by an occupational therapist. During a tour of the premises it was obvious aids such as grab rails, call bells and assisted bathing were provided. Furniture in service users bedrooms was arranged to meet their individual needs.St Margaret`s LtdPage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES 16 14 3 2 3 16 00 0 3 0Key findings/Evidence Standard met? The home provided the same individual space as at 31/3/02.St Margaret`s LtdPage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? The home had single and shared rooms. Three bedrooms, two single and one shared, were inspected against this standard. Service users said they were happy with their rooms and with the way they were arranged. Rooms were clean, neat and tidy with no unpleasant smells noted. Rooms were personalised with small items of furniture, pictures and ornaments. Personal clothing was neatly stored and sensitively labelled. Screening was provided in the shared room. None of the rooms inspected had bedside or over bed lights. Some paintwork on doorframes and skirting boards was damaged and needed repainting. Requirement 7 and recommendation 3. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? All rooms had radiators fitted. These had protective covers. A landlords gas certificate dated 5/7/04 was seen. Windows above the ground floor only opened at the top. These openings were not restricted. Rooms were ventilated and the temperature was comfortable. Emergency lighting was provided and was last serviced on 16/6/04. Recommendation 4. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home had an infection control policy. Hand washing facilities were provided where waste was handled. A separate laundry area was provided. This had one washing and two drying machines. Both were in working order. The washing machine had a sluice facility and the laundry had impermeable floor covering.St Margaret`s LtdPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X3 Key findings/Evidence Standard met? Staff rotas were kept. The home had three members of staff on in the morning and afternoon and two at night with the manager hours as extra. At night an on-call system operated. Staff rotas seen supported this information. None of the staff team were under twenty one years of age. One member of staff was on duty from 8 ­ 1 each day to undertake domestic chores. Domestic staff said they felt adequate hours were provided to enable them to do their work.St Margaret`s LtdPage 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.St Margaret`s LtdPage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This standard was not assessed. There had been no management changes since the last inspection.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? This standard was not fully assessed. However a requirement made at the last inspection remained unmet. The inspector agreed to send the manager copies of the Commissions suggested formats for Regulation 26 visits. This was done following the inspection. Requirement 8.St Margaret`s LtdPage 30 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed.St Margaret`s LtdPage 31 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records inspected included care plans, accident, medication, staff rotas, menus and safety records. Where records required improvement this has been addressed under individual standards.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Staff said they had access to moving and handling training. Hoists and assisted baths were last serviced on 1/6/06. The fire alarm was tested weekly, the system was last serviced on 16/6/04, and the last recorded fire drill was held on 25/11/04. Systems were in place to enable staff to practice infection control. The home had a health & safety policy. All accidents were recorded and notifications sent to the Commission as required by regulation 37. Safety procedures were displayed. The manager was aware of the need to comply with other legislation relevant to running a care home.St Margaret`s LtdPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateSignature Signature SignatureSt Margaret`s LtdPage 33 Public reports It should be noted that all CSCI inspection reports are public documents.St Margaret`s LtdPage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleSt Margaret`s LtdPage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here St Margaret`s LtdPage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.St Margaret`s LtdPage 37 St Margaret`s Ltd / 9th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000006785.V194782.R01© This report may only be used in its entirety. 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