Inspection on 11/11/05 for St Margarets`

This inspection was carried out on 11th November 2005.

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` 27/07/09

St Margarets` 28/09/07

St Margarets` 27/06/06

St Margarets` 15/02/06

St Margarets` 04/02/05

St Margarets` 07/06/04

St Margarets` 13/02/04

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

CARE HOMES FOR OLDER PEOPLE St. Margarets` 84 West Heath Road Hampstead London NW3 7UN Lead Inspector Ms Franki Solomon Unannounced Inspection 11th November 2005 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` DS0000037259.V265543.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` DS0000037259.V265543.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St. Margarets` Address 84 West Heath Road Hampstead London NW3 7UN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8731 7737 020 8731 8686 claire.cunden@camden.gov.uk London Borough of Camden Katherine Ann Babbington Care Home 44 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (44) of places St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate the named individual under the age of 65 suffering from Dementia, named in the application on condition that the registered manager ensures that all his assessed needs can be met at St Margarets Care Home 4th February 2005 Date of last inspection Brief Description of the Service: St Margaret’s is a modern Care Home owned and managed by the London Borough of Camden and is situated near Hampstead Heath. The Home is registered with the Commission for Social Care Inspection under the Care Standards Act 2000, to provide support for up to forty four (44) Older People with a form of dementia. St Margaret’s opened in July 1999. The house wasacquired by the London County Council in 1953 and acquired by London Borough of Camden in April 1965 and has been used as a care home at least since that date. The home has five storeys including lower ground floor and has a 2-storey extension to the rear. The home is accessible to people with disabilities. The entrance leads into a smart reception area and reception room. The home is set out in five units. Four units accommodate nine residents and the fifth unit accommodates eight residents. There are 36 single rooms and 4 shared double bedrooms. At the time of inspection there were 5 vacancies, including 1 double room. Each unit has it’s own kitchenette with dining area and lounge. There are two additional lounges with television and stereo. One is normally used as a quiet area. The manager’s office and general office are on the ground floor, with the laundry to the rear. The main kitchen is on the lower ground floor. The home provides 24-hour care. The Registered Manager was not in post due to illness. The home has in place an Acting Manager who was an Assistant Manager, and has been with the Home since the it opened. The Acting Manager is assisted in the running of the Home by three Assistant Managers, three Senior Care Workers, a Staff Team of Support Workers and Ancillary Staff. The Home is set in its own grounds, has a large garden, terrace, and parking to the front. The Home which is near Hampstead Heath in North London is not easily accessible. Public transport – bus or train – is about ½-hour’s walk away. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first statutory inspection for the year April 2005 – March 2006. The inspection was over a period of 6-1/2 hours. The inspection was to check the requirements made at the last inspection and to inspect the key standards. Residents were spoken with, staff were observed and spoken with, files and documents were examined and a tour of the building. The Acting Manager was available and an assistant manager came on duty in the afternoon. The inspector would like to thank the management, staff and residents for their hospitality and co-operation. What the service does well: What has improved since the last inspection? What they could do better: The Home’s recording formats for assessment and care plan could be improved to ensure staff are able to identify, assess and record appropriate needs of service users, also to enable staff to do a Lifestyle Assessment, so that service users may benefit and receive appropriate and professional support. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 6 Training, such as dementia training was not acted upon by some staff. Sounds and noise are particularly disturbing for people who are confused or have dementia. Health and Safety policies and procedures are not always observed by staff and residents as well as staff could be at risk. Staff’s training could be reviewed. Identified activities for staff should be given consideration and efforts made to act upon them. Despite the points raised here, the inspector would like to acknowledge that the two deputies and staff have ‘held the fort’ well in the absence of the Registered Manager. 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` DS0000037259.V265543.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` DS0000037259.V265543.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): 1, 3. Std 6 is n/a as the home does not provide intermediate care. The home’s Statement of Purpose gives all the information to enable service users to make an informed decision. The Statement of Purpose details a comprehensive Complaints Procedure but does not give the details of the Commission’s locality office. The assessment process needs to be reviewed to be more comprehensive to ensure service users’ individual needs are identified and met at the home. In general staff demonstrated an adequate level of knowledge about service users’ needs. However it was not clear whether the service user or their relative had been involved in the planning of their care, or whether they agreed to the plan of care. EVIDENCE: The Statement of Purpose gives full and detailed information for service users to make an informed choice but does not include the Commission’s details in the complaints procedure. The Assistant Manager took up the post of Acting Manager on 14th November 2005 whilst the manager was off on sick leave. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 9 A random sample of service users’ care plans was examined. These did not have sufficiently comprehensive assessment to give useful information for staff to deliver a relevant service. For instance there was no Lifestyle Assessment of the service users. Without this knowledge staff cannot have a relevant conversation with service users which would involve and enable service users to reminisce about their own lives. Assessments and care plans also did not enquire or indicate how the service user would like to be addressed. The inspector heard service users all addressed by their first name. A requirement has been made in terms of the assessment format and care plan. The inspector spoke with a service user and noticed that the service user’s dentures were in need of cleaning. The care plan format itself did not allow for individual needs such as personal hygiene or dental hygiene to be identified and appropriate action to be taken. In discussion, the acting manager did advise that plans were in the pipeline to review and update the care plan format at a future date. A requirement has been made under this and standard 7. The sample of care plans was not signed off by the service user or their relative / advocate to indicate that the service user or their relative (where possible) had been involved and agreed to the plan of care. A requirement has been made. Assessments need to consist of activities of daily living to include some of the following: • • • • • • • Personal care and hygiene Nutritional screening – nutritional status (any special dietary needs, eg diabetes) Assistance with mobility (if necessary) Health care and psychological needs Continence assessment Lifestyle, social, (aspirational) and cultural needs Moving and handling arrangements The inspector sat in on a staff handover and staff spoken with generally had adequate knowledge of service users needs. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The care planning system in place, although not robust, generally enables staff to provide staff with information to meet service users’ general needs. The needs of service users’ with dementia were not observed. Service users have access to external healthcare professionals. The system in place for the management and administration of medication is adequate and should ensure service users’ medication needs are met. A requirement has been made in terms of training, and a recommendation has been made in terms of the safe keeping of medication. Not all staff knew what some medication of service users’ was for and their side effects. The recording system on the administration chart indicated the resident had not taken their medication. However, it did not say why the resident had not taken their medication. A requirement has been made. Staff treat service users with willingness, kindness and patience. Staff understand the theory of dignity, privacy and respect. EVIDENCE: St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 11 Staff made the best use of the care plans available. A sample of care plans recorded most of the service user’s needs but did not enable staff to give the best support. For instance; • a service user’s dentures were in need of cleaning. The care plan format did not “prompt” staff about the need for dental hygiene. • another care plan indicated: “ensure ‘resident’ has an eye test every six months. There was no date in the care plan as to when the last eye test had been undertaken and when the next eye test was due. The staff said, that information was in another file in the office. A requirement has been made. As indicated under Standard 3 an example of; • what the individual needs should include • the action that needs to be taken • date of when the action was undertaken and • the date for the follow up. • Also, care plans and action plans should have the date of the next review. At staff handover, one staff’s records clearly indicated the food intake of service user’s on that unit. This was good practice and enabled staff to be aware of service users’ appetite and nutrition. It would be beneficial to all service users if all staff could adopt similar recording and handover. When the inspector went into the lounge to speak with a service user, there were service users with dementia. Both the television and the radio were playing. Such ‘noise’ can be particularly distressing for people with dementia. Although staff said they had had introductory training to dementia, the training was not used in the interest of service users’ or to their benefit. The music was not to the culture and age of service users. A requirement has been made under this standard and under Standard 30. The care of a service user who had had a skin graft was discussed and the service user seen. The dressing was carried out by a District Nurse. The service user indicated they were happy with the care being provided. Input from other health care professionals included Occupational Therapist, Chiropodist, Optician and Dentist. Arrangements for management of medication were assessed. The policies and procedures for medication were clear and detailed. Except for one service users, none of the service users were self-medicating. A staff member left keys in the medication cabinets whilst leaving the room briefly to assist a service user. The staff member apologised immediately and said they realised that should not have happened. A recommendation about the safe keeping of medication has been made. Medication checked tallied with records on units St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 12 inspected. Not all staff knew the purpose of all medication, nor did they know the side effects of medication. A staff member said they were aware of their deficiency and had signed up for medication training scheduled for January 2006. A requirement has been made. Service users indicated in comment cards, and when spoken with, that they were happy at the home and said they had no complaints. Staff were observed to knock on doors before entering. Some service users who are confused or had dementia were seen to be distressed. Staff showed patience and understanding. A service user who expressed distress and asked to phone their relative was assisted to the office to do so. The office and office staff were freely available to residents who were in and out throughout the day of inspection. It was not known whether service users preferred to be addressed by their first name as was used by staff. A requirement has been made under this standard and standard 2 in terms of the assessment and care plan format. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 13 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): 12, 13, 14 & 15. Although activities and outings are undertaken at the home, the arrangements for activities and community involvement is not well publicised or recorded in the home. The home is not able to resource Local Authority Day Centre places. Visitors are welcome at the home. It was not clear whether service users and /or relatives were involved in the planning of their care. The menus and meals were varied and enjoyable. EVIDENCE: The home has an Activities Programme which looked sparse as though not much was happening. The notice publicising a forthcoming event was not prominently displayed. The inspector gained the impression that there were not many activities. When the inspector sat in on the handover at 2 p.m. it became clear that a Tai Chi activity had taken place that day, and that some service users had gone out. During handover it became clear residents’ wishes were observed, for instance one resident had chosen to get up late and not disturbed. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 14 Upon examination of the care plans, staff used the format available well, information was well set out, clear, relevant, and to the benefit of service users. St Margaret’s has difficulty in accessing Day Centre resource. The inspector spoke with one service user who had attended a local Day Centre. The service had gradually been removed and it was clear the service user missed the service very much. The acting manager advised that although the Home was aware the service user missed the service, the home was unable to persuade the Local Authority Day Centre or Care Manager to come to an arrangement to continue to provide and meet this service user’s identified need. A recommendation has been made. One service user’s care plan indicated they liked to be outdoors. There was nowhere to indicate whether this identified need had been actioned. It appeared this activity was not undertaken because of shortage of staff. A requirement has been made in terms of identified needs and staff availability and under standard 27. Service users care plans were not signed off by themselves or their relative / respresentative to show they had been involved or agreed to the plan of care. Visitors and relatives were at the home on the day of inspection but were busy with their relatives and were unable to talk with the inspector. Service users said they enjoyed the meals. The inspector sampled the meal. It was Friday and fish & chips were served. It was tasty. The menu on the tables showed a varied and nutritious meal. However, because the home attempts to keep the home homely, the menus on the table are in small print, in 7 columns for the seven days, and for each meal of the day in each column. The menu plan is unhelpful to older people, to people who use spectacles, and people who have dementia. The inspector did not find it easy to find the day of the week on the menu and where the meal of that day was on the menu card. A person with dementia would experience even greater difficulty. A recommendation has been made in terms of having a large white board or similar, to indicate clearly the meal of the day, despite that this may give the home an institutional feel. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 15 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): 16 & 18. The arrangements are in place for handling complaints and are good for the home but it is incomplete. To date one complaint remains outstanding and is being dealt with appropriately. The arrangements in place for adult protection need to be improved. The acting manager needs to ensure that all staff have a better understanding of adult protection issues. Failure to ensure such could place service users at risk. EVIDENCE: There is a complaints procedure in place and written information was displayed within the home on how and who to complaint to. The Statement of Purpose also holds the full complaints procedure but it does not give details of the Commission’s locality office if the complaint remains unresolved. A requirement has been made under standard 1. Residents spoken to said they felt confident to complain to the staff or to the manager if they had a complaint. But they said they had no complaints. Arrangements in terms of policies and procedures were in place and one complaint was being dealt with appropriately. Adult Protection policies and procedures were available. Staff confirmed that they received training as part of their induction training and there records of this. However, not all staff interviewed knew the term St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 16 “Whistle blowing” or what appropriate action to take if they witnessed abuse or if an allegation of abuse was reported to them. One staff member (who was an agency staff) said they would talk to the person. Another member of staff (permanent) was very clear on the appropriate action to take. This was discussed with the manager and demonstrated a need to review the outcome of adult protection training and the induction for agency staff. A requirement has been made under standard 30. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 17 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): 19 & 26. The standard of the environment within the home is good, providing service users with an attractive home. Some staff do not always observe safe practice and can put their own and staff and service users’ safety at risk. Some of the rooms seen were personalised and others not. The home was clean and homely, but decoration is required in certain areas in the lounge. EVIDENCE: The home was generally, clean, well furnished, equipped and generally safe. However; • on the top floor landing where residents smoke, the carpet was studded with cigarette burns. The acting manager advised an alternative floor covering was being researched. A requirement has been made. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 18 • When inspecting the sluice room, the floor was strewn with cleaning tools and buckets. The doors are not locked and presented a safety hazard to both service users and staff. The acting manager had the room made safe immediately. A requirement has been made. One sluice was not working, the environmental health department’s advice was being sought as to whether alternative methods of disposing of sluice material could be used. A requirement has been made. In one of the bathrooms the electric bath chair was out of order due to an electrical fault. Parts were on order for the chair to be repaired. A requirement has been made. The hot water in one of the bathrooms ran too hot. Having held her hand under the running hot water, the staff felt the temperature was fine. The inspector was unable to keep her hand under the running water, finding it too hot. A thermometer read 48 degrees when the water should between 42 – 43 degrees. A requirement has been made here and under standard 38. In some of the small lounges the backs of chairs had rubbed against the walls which were scuffed. Decoration is required. A requirement has been made. • • • • St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 19 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, 28, 29 & 30. The staffing arrangements during the inspection aroused some small concern about the numbers of staff ratio to meet service users needs. The recruitment and vetting of staff was carried out appropriately and should ensure the safety of service users. The induction programme for permanent staff is robust, but agency staff’s basic skills and experience need to be checked more thoroughly. EVIDENCE: The full complement of support and care staff was either the acting manager or, in the afternoon the assistant manager, and 10 care / support workers including team leaders. This meant two support workers to four service users. One service user’s care plan indicated they liked to be outdoors but the care plan did not record when such an outing or walk had taken place. It was not possible for one care worker to accompany a service user out and leave one support worker with the remaining 8 service users on the unit. A requirement has been made in terms of staffing ratios. There is a need to ensure that all staff has sufficient knowledge on how to support people with dementia in addition to ensuring there is a system in place to review that training is appropriately applied. This is particularly in terms of the 1-day training on dementia, yet the radio and television were both on in the lounge despite the staff having had dementia training. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 20 Agency staff were not clear about ‘whistle blowing’ or what to do in the event of an allegation of abuse. A requirement has been made. Staff training profiles evidence the training received. Most of the staff has had National Vocational Qualification (NVQ) – Level II and some were planning to undertake the NVQ – Level III. A recruitment procedure is in place. A sample of staff personal files was checked St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 21 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): 31, 33, 35 & 38. The Registered Manager is off on indefinite leave and the assistant manager has been promoted to be acting manager in the meantime. She has been employed at the home since it opened. The acting manager will have to put in an application with the Commission for registration. The acting manager took up the post at the time of inspection. The acting manager is committed and able to continue a good standard of care and is supported by the remaining assistant manager and a trained and experienced staff team. Arrangements in place should ensure the safe and effective running of the home for the benefit of service users and staff. Service users’ finances are appropriately and safely recorded. Arrangements for the safety of staff and service users were in place, but not always adhered to. EVIDENCE: St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 22 The acting manager has taken up the post of acting manager from 14th November 2005 in the absence of the registered manager. The acting manager must put in their application with the Commission to be assessed for “fitness”. Evidence gathered during the inspection process demonstrated that the home has been well managed during the preceding months of the registered manager’s absence and that the acting manager is well supported by her line manager, external to the home. A requirement has been made under standard 1. A random sample of residents’ finances were checked with the administrator. The checks and balances were correct. A quality monitoring system was in place to obtain the views of service users. Monthly Regulation 26 reports demonstrated service users and staff views are listened to and their concerns acted upon. The format of the care plans was discussed with the acting manager who advised that a revised system was being researched. Policies and procedures for the safety of residents and staff were in place. Certificates and checks were all current. There were not always adequate risk assessments in place in respect of health and safety, this is in terms of standard 19 & standard 38 where equipment was left unsafe in the sluice room and the water temperature in the bathroom reached 48oC. St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4(1)(c) Requirement The Registered Person must include details of the Commission for Social Care Inspection in their Statement of Purpose. Timescale for action 24/12/05 2 OP3 12(2)(3) 3 OP7OP8 12(1) 14(1b) 15(1c) 4 OP3OP7 15(1)(2)( a-d) The Registered Person must 24/06/05 ensure a full assessment is undertaken to ensure the needs of service users are fully identified and met. 24/12/05 The Registered Person must ensure service users care plans are evaluated and reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned, to ensure the service users’ changing needs are appropriately met. An example being to a service user whose dentures were in need of cleaning. The Registered Person must; 15/02/06 • ensure service users or their representative have been involved in their plan of care, and have the care plan signed by the service DS0000037259.V265543.R01.S.doc Version 5.0 Page 25 St. Margarets` 5 OP9 13(2) 13(4bc) 6 OP12OP27 12(1)(a)( b) 7 OP19OP26 OP38 23(2)(d) 16(2)(j) user or their relative / representative. • service users’ are consulted on how they prefer to be addressed. The Registered Person must 15/12/05 ensure that; • only staff who have been appropriately trained, administer medication. • medication that has not been taken is clearly indicated on the chart. • staff take into consideration the needs of service users and act upon them appropriately. The Registered Person must 15/01/06 ensure; • service user’s identified needs, such as stimulation through leisure and recreational activities in and outside the home are taken into account and arrangements made in terms of staffing to reasonably meet those needs. • staffing ratios are adequate to meet the identified needs of service users. The Registered Person must 24/03/06 ensure; • the home is well maintained. • consult with the Environmental Health Department and obtain a report about; 1. the need for sluice machines all areas in the home are kept tidy and free from hazards. The inspector acknowledges the Acting Version 5.0 Page 26 • St. Margarets` DS0000037259.V265543.R01.S.doc 8 23(5) manager had the area cleared immediately. • Residents are kept free from hazards and have hot water temperatures recorded daily and ensure washing and bathing water for residents do not exceed 44 degrees. The Registered Person must have the scuffed areas in the small lounges repaired or 28/06/06 decorated. 9 OP30 13(6) The Registered Person must 15/01/06 ensure; • staff have the appropriate training and experience to ensure the safety of service users. This refers to Agency staff who were not familiar with the Protection of Vulnerable Adults policy and procedure • Agency staff must have appropriate induction on the start day of their duty. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations For staff to take all precautions regarding the secure handling of medication. The inspector acknowledges the keys were left in the cupboard only briefly when staff attended to the urgent needs of a service user. To make representation behalf of the resident to Camden Local Authority Social Services to re-instate Day Centre DS0000037259.V265543.R01.S.doc Version 5.0 Page 27 2 OP12 St. Margarets` 3 OP15 facility for the service user who enjoyed the Day Centre and whose place had been withdrawn. When the inspector spoke with the service user it was evident the service user missed the friends, the outing, the environment and the experience. To have the menu available to service user in a format and design that is both easy to read and accessible to people who may be confused or who have dementia. (A menu in small print, for the 7 days of the week is not helpful to older people or people who have dementia). St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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. Extracts may not be used or reproduced without the express permission of CSCI St. Margarets` DS0000037259.V265543.R01.S.doc Version 5.0 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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