Inspection on 10/01/06 for St Margarets

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Margarets 18/07/08

St Margarets 19/07/06

St Margarets 21/06/05

St Margarets 06/12/04

St Margarets 17/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE St Margarets 17 Brookvale Road Highfield Southampton Hampshire SO17 IPW Lead Inspector Janet Shipman Unannounced Inspection 10th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 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 Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Margarets Address 17 Brookvale Road Highfield Southampton Hampshire SO17 IPW 023 8058 4877 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) Mr Thorne Mrs Thorne Mrs J Francis Care Home 18 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (18), Mental disorder, excluding learning of places disability or dementia (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (18), Old age, not falling within any other category (18), Physical disability (4) St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A total of four service users may be accommodated between the ages of 55 and 64 Service users in the DE and MD categories must be at least 55 years of age A maximum of four services users may be accommodated at any one time in the PD (E) category 21st June 2005 Date of last inspection Brief Description of the Service: St Margaret’s is a care home situated in Highfield, Southampton. The home is registered to provide care to eighteen service users within the categories of old age. The home also accommodates service users who have a physical disability, dementia, mental health issues and four service users over the age of 55. This has been agreed part of the conditions of registration. The home is a large detached property and comprises of accommodation in both single and double bedrooms arranged over two floors. The home also has two lounges, a dining room and a smoking room situated on the ground floor. The home has a stair lift, which enables service users to access both floors of the home. To the rear of the property is a car parking area and to the front of the property is a large well-maintained and pleasant garden. The home is situated close to local facilities and is a short journey away from Southampton. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second unannounced visit of the year and was undertaken by one inspector. Two service users were seen privately in their bedrooms and one service user in the communal lounge. Records seen included care plans, risk assessments, food monitoring records, fire records and recruitment files. Two members of staff and the manager were spoken to as part of the inspection. Primarily the inspection focused on following up on requirements raised at the last inspection, as most core standards had been audited at the last inspection. What the service does well: What has improved since the last inspection? The proprietors and manager have made great improvements over the last year in the environment and the running of the home. Most of the home has been redecorated. New carpets have been laid, new furnishings have been purchased, a new kitchen and bathroom has been installed and a number of bedrooms have been redecorated and again furnished with new carpets, beds and bedroom furniture. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 6 The garden at the side of the house has been redeveloped to provide a safe and attractive seating area. The home has introduced new procedures and documentation to ensure service users needs are being met. Assessment information, care plans and risk assessments are more comprehensive and detailed. A manual of the national minimum standards has been produced in an easy to read format to inform staff of the standards they are expected to meet when working in the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4, & 5 were assessed at the last inspection. Key Standard 6 was not assessed at the home does not provide this service. EVIDENCE: St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Key standards 7, 8, 9 & 10 were assessed at the last inspection. Care plans and risk assessments are detailed and outline how the care should be delivered. Medication records were clear and coordinated with the medication administered to service users. EVIDENCE: A requirement was made at the last inspection to ensure that care plans and risk assessments are in place for service users. Care plans and risk assessments have been reviewed and updated since the last inspection. The care plans seen were generated from a detailed assessment. The care plans give clear guidance to staff on how to meet individual service user’s needs. Individual risk assessments are carried out and now include risk assessments for service users who have been assessed as having a risk of falls. A requirement was made at the last inspection for the home to review with the pharmacist the arrangement for ensuring the medication coordinates with the medication ‘Mar’ sheet. This has now been completed and from the Mar sheets St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 10 viewed by the inspector the medication start time coordinates with the administering of medication and was clearly recorded. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Key standards 12, 13, 14, & 15 were assessed at the last inspection The home keeps food monitoring records of service user meals and alternatives given for service users who maybe ill. EVIDENCE: A requirement was made at the last inspection to ensure the home keeps a record of the meals eaten by service users. The manager stated that records were taken at the time of the last inspection but were kept in the main office. Since the last inspection the manager has purchased a two draw lockable filing cabinet, which is installed in the kitchen area. The food monitoring records are now kept in the cabinet. The inspector viewed the records, which were found to be satisfactory, and included additional information such as weight charts to monitor weight loss. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Key standards 16 & 18 were assessed at the last inspection EVIDENCE: St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 23 Standards 19, 24, 25 & 26 were assessed at the last inspection. The home provides safe and attractive accommodation with a range of communal facilities. Service users rooms provide the appropriate equipment to meet their needs. EVIDENCE: The home has been undertaking an extensive renovation programme. The majority of the home has been redecorated, a new kitchen and bathroom has been installed, new carpets have been fitted and new furniture and furnishings have been purchased. The communal facilities within the home include two lounges one which has a television and new DVD player and the other lounge has a CD player for listening to music or just wanting a quiet area to sit. There is a large dining area and a conservatory area for service users to smoke. Outside of the home the side garden has been renovated to provide attractive seating area for service users to sit in the summer months. One service user told the inspector St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 14 that she couldn’t wait to be able to sit outside again when the weather gets warmer. Service users spoken to were very pleased with their rooms and said they had everything they wanted. Service users are able to bring their own furniture to the home, by arrangement. All rooms that were seen by the inspector were clean and tidy and most had been redecorated and refurnished with new carpets, new beds and new wardrobes. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 Key standards 27, 28, 29 & 30 were assessed at the last inspection. The manager is looking at ways to provide both mandatory and additional training for staff. The home has reviewed their recruitment processes and is ensuring that references are obtained for all new staff. EVIDENCE: A requirement was made at the last inspection for the home to provide specific training in mental health, dementia and Parkinson’s. The manager informed the inspector that she was looking at ways in which this could be provided through a local college. The manager also informed the inspector that she was also looking into ways in which mandatory training could be provided by employing a trainer to deliver the courses in-house. Progress will be reviewed at the next inspection. A requirement was made at the last inspection for suitable recruitment procedures to be put in place for new staff. The manager informed the inspector that they have reviewed their procedures and put in new guidance to ensure that references are obtained. The inspector viewed the file of the latest applicant to apply for a position in the home. The manager had obtained references for the applicant but the applicant had not completed the details sufficiently on the application form. The manager agreed to ensure that this was done in future. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 & 38 Standards 32, 33 & 36 were assessed at the last inspection. The home has started to introduce its quality assurance system for the home. The home supports service users to ensure their financial affairs are safeguarded. The home has implemented formal supervision sessions for staff. The health and safety of service users are promoted by clear policies and procedures. EVIDENCE: St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 17 The home will shortly be introducing a new service user/visitor questionnaire to obtain feedback about the service. The inspector discussed with the manager the need to develop an action plan from the results of the questionnaires and send a copy to the CSCI. Recently the home has set up a comments book for visitors and visiting professionals have made positive comments about the service. The home is also going to introduce a suggestions box for service users and visitors to make comments about the home and these will be reviewed on a regular basis. Although the home does not directly get involved in managing service users finances, the manager gave examples of supporting service users to receive their financial entitlements through liaising with appointees and family members. Relatives generally arrange for the purchase of clothes or any other items for service users. The manager has set up formal supervision sessions with staff and showed the inspector the timetable of supervisions to be carried out and notes taken from previous supervisions. The manager commented that she spends a lot of time working with staff and undertakes informal supervision through observing practice. This was confirmed by a member of staff who stated that the manager could give you ideas on how to undertake a task differently. The home keeps records of all checks on fire equipment, COSHH analysis and risk assessments. They were made available at the inspection. There are health and safety policies and procedures and staff are aware of having to read new policies. St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 3 X X 3 X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Margarets DS0000011792.V271483.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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