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Inspection on 11/07/08 for St Margarets

Also see our care home review for St Margarets for more information

This inspection was carried out on 11th July 2008.

CSCI found this care home to be providing an Good service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides support to the people living in the home in a personal manner, and care staff are provided with a high level of training to meet the needs of the individual. The manager felt that they provide a very caring service and that the residents are happy and content. People we spoke to during our visit reinforced this, saying that the home was `lovely` and that the staff were `very kind and helpful` and that `we are able to do things we enjoy` The premises are homely, and comfortable and the rooms well equipped and a range of activities and events are available to the people living there. People living there are supported to continue activities that they enjoy with support from staff where needed.

What has improved since the last inspection?

Since the last inspection, new procedures have been introduced to ensure that all recruitment checks are in place, and that medication is safely administered, and new staff rotas provide more flexibility and ensure that sufficient staff are available at the right time of day.

What the care home could do better:

The individual care plans need some further work to ensure that they reflect changes in individuals needs, and show what the desired outcome for the person is. The continued refurbishment planned will ensure that facilities remain of an acceptable standard

CARE HOMES FOR OLDER PEOPLE St Margarets 22 Aldermans Drive Peterborough PE3 6AR Lead Inspector Alan Buttery Unannounced Inspection 11th July 2008 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 DS0000015187.V369045.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 Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margarets Address 22 Aldermans Drive Peterborough PE3 6AR 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) 01733 567961 F/P 01733 567961 Mr Riaz Mawani Mrs Sayida Mawani Ms Kathleen Gregson Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (16) St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The four places for service users with dementia (DE(E)) are for four named individuals The one place for LD(E) is for one named individual Date of last inspection Brief Description of the Service: St Margaret’s is situated in a predominantly residential area of the city of Peterborough near to Peterborough District Hospital. The home is close to local shops and transport routes. St Margarets is a three story, semi-detached property that has been adapted from a family residence for use as a residential care home for older people and one service user with learning difficulties. A stair lift serves the three floors. The home was built in approximately 1920. The home has successfully created a homely atmosphere, an objective that is aspired for in their Statement of Purpose. Fees charged at the time of this inspection were between £320 and £420 per week. Eleven people are part funded by a Local Authority whilst four people funded their care privately. CSCI reports are available at the home and one was placed on a table near the entrance. St Margarets DS0000015187.V369045.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced visit, and we looked at the key minimum standards for older people. During our visit, the manager of the home was available to provide information and documentation required, and as part of our visit we spoke to some of the people living in the home and staff working on the day. What the service does well: What has improved since the last inspection? Since the last inspection, new procedures have been introduced to ensure that all recruitment checks are in place, and that medication is safely administered, and new staff rotas provide more flexibility and ensure that sufficient staff are available at the right time of day. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service ensures that it gathers full information before anyone moves in, ensuring that the person moving in can be confident his or her needs will be met. EVIDENCE: The service has a procedure for managing the admission of new residents in the home and this was discussed with the manager. The service has a mixture of privately funded and local authority funded residents, but the procedures followed are much the same. Wherever possible, the person looking to move into St Margarets would visit the home, and if this was not possible, in many cases families visit on their behalf. The manager of the home would then arrange to complete a full assessment of need, to determine whether the home would be suitable, and that they could St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 9 meet the identified needs. As part of the assessment they also undertake a risk assessment, ensuring that any equipment that they may need would be available. Initial care plans are written to ensure that on arrival, the needs identified are met in a way the individual would prefer, and these are discussed with the person moving into the home, or if this is not possible, with close family members. These initial plans are reviewed after the first 4 weeks as part of their quality review. The Home does not offer intermediate care. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual plans are available to ensure identified needs are met, although more information needs to be included, and procedures are in place to ensure that medication is administered safely. EVIDENCE: As already indicated, initial care plans are prepared prior to someone moving into the home, and these are reviewed and developed in the first few weeks of the persons stay, and reviewed on a regular basis thereafter. The manager said that they have an excellent relationship with local health professionals, who provide support to staff as well as to the people living in the home. The individual plans record health activities, professional visits, weight and blood pressure readings. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 11 As part of the inspection we looked at care plans for three of the people living in the home, which contained the basic information about the individuals. However, we discussed further improvements that were needed, to ensure that all the needs identified were covered by the plans, and that they show outcomes for the person they related to. The service would always look to support someone who was able to manage their own medication, but at the present time, they do not have one living in the home that does so. Medication support is provided by their local pharmacy along with training for staff who assist with the administration of medication. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living in the home are encouraged to take part in a range of activities, and are supported by the home to take part in things they enjoy. EVIDENCE: The home does not employ a specific activity person, but expects care staff to spend time with people in the home, including sometimes sitting and talking with them, or giving a hand massage. A record of the likes and dislikes of the people in the home is kept, and things that they do are recorded. A range of activities are available in the home for the people living there. A selection of games are available including skittles, bowls and quoits as well as board games as well as books to read. If someone living in the home prefers it, staff will sit and read a book with them at times. They hold an exercise session twice weekly for those assessed by their GP as fit enough to take part and regular entertainment. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 13 They also support one of the people living there to go to the football regularly, accompanied by a staff member, and many of the families take their relative out, for example the son of one of the residents takes his father to the local pub on a Sunday. A local vicar holds a communion service once a month, and a Methodist minister is available should anyone want to see him. The home provides a choice of home cooked food, which is appreciated by the people in the home, and they find that the people living there prefer ‘old fashion ed meat and two veg’ Meals are served in a small dining room, although some of the people living in the home prefer to sit in one of the lounges or eat in their room. We spoke to three people and they all said their food was very good. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure that any complaints, concerns or allegations are appropriately dealt with. EVIDENCE: Although no complaints have been received since the last inspection, procedures are in place to ensure that any complaint is appropriately dealt with. All staff receive adult protection training as part of their initial induction training as well as regular updates. One safeguarding issue has been reported this year, which was managed in accordance with their policy, and the member of staff disciplined. There was no evidence of the incident being malicious, and the member of staff has not been dismissed but is being appropriately supported and supervised. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service provides a clean and homely setting for the people living in the home. EVIDENCE: On the day of our visit, the home was clean and free from any unpleasant odours. The home was formerly a domestic residence and although extended still retains a homely feel to it. The wall to the front of the home is new and new windows have been fitted in the last year and some of the rooms have been redecorated, and some further works have been done in the back garden, with the patio re-laid. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 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. A well trained and motivated staff team ensure that the needs of the people living in the home are met, and recruitment procedures are followed so that all required information is obtained before new staff start working in the home. EVIDENCE: As part of the inspection, we looked at the staff files for three of the care staff in the home, which all contained the required information including application form, references, training records, CRB disclosures and supervision notes. All staff receive the training necessary for their role, and in addition to the mandatory training also receive additional training in dementia. Since the last inspection, the normal; shift patterns have been changed, and this provides more care staff at key times. In addition a cleaner is now employed taking the responsibility off the care staff. Procedures have changes since the last inspection to ensure that new staff are not able to start until the required checks are in place. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is very well managed and procedures are in place to ensure that people living in the home are able to make their views known. Procedures ensure the health sand safety of people working and living in the home. EVIDENCE: The service is well managed, and since the last inspection, the manager has successfully completed her NVQ level 4, as the top student, and during the inspection she was seen to be well respected and liked by both residents and staff. During a tour of the premises, all the residents were keen to talk to her, and she was happy to spend time with them. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 18 Although supervision of staff is taking place, it is not currently in line with the requirements. Records we examined during our visit showed that staff were receiving supervision every three or four months and a more formal procedure needs to be in place. People living in the home are supported to make choices in all areas of their day-to-day lives, and staff encourage them to make any views known. Regular residents meetings are held which discuss events and meals and give the people in the home the chance to discuss any planned changes, and an annual quality assurance survey ensure that residents and family members can contribute to the running of the home. Health and safety policies are in place and staff receive training to ensure that there are no risks to either people living or working in the home. St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 19 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 3 X 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 20 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. 1 Standard OP7 Regulation 15(1) Requirement Individual plans must show how the person they relate to is involved and what the planned outcome is, and show where changing needs are included, to ensure individual’s needs are met. Timescale for action 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Margarets DS0000015187.V369045.R01.S.doc Version 5.2 Page 22 - 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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