Inspection on 13/12/05 for St. Margarets

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St. Margarets 06/06/06

St. Margarets 07/06/05

St. Margarets 19/01/05

St. Margarets 05/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Margarets St Margarets Care Home 99 Carlisle Road Eastbourne East Sussex BN20 7TD Lead Inspector Lucy Green Unannounced Inspection 13th December 2005 10:30 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 DS0000046888.V255906.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 DS0000046888.V255906.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Margarets Address St Margarets Care Home 99 Carlisle Road Eastbourne East Sussex BN20 7TD 01323 639211 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) office@saint-margarets.co.uk Total Support Solutions Ltd Miss Teresa Howell Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-two (22). Service users must be older people aged sixty-five (65) and over on admission. 7th June 2005 Date of last inspection Brief Description of the Service: St Margaret’s is registered to provide residential care to twenty-two older people. At the time of the inspection, fifteen people were accommodated. The home is a large, detached, three-storey, Grade 2 listed building situated in the Meads area of Eastbourne. The home is located within walking distance of local amenities and the main seaside town is a few minutes drive away. Resident accommodation consists of sixteen single rooms and three shared rooms. Many of the bedrooms have ensuite facilities. Communal areas comprise of a lounge, reception and landing seating areas and a large dining room. The external grounds offer an attractive and well maintained garden to the rear of the property. Parking facilities are available at the front of the home. The home has a series of chair lifts which enable residents to access all three floors of the home. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at St Margaret’s have requested to be referred to as ‘residents’. This unannounced inspection took place over five and a quarter hours on 12th December 2005. This is the second inspection of this year and therefore this report should be read in conjunction with the report from the announced inspection carried out on 07 June 2005. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. A tour of the premises took place, care, medication and recruitment records were inspected. The Inspector spoke individually with five residents. The Manager, three staff, and three visitors were also spoken with during the inspection. What the service does well: What has improved since the last inspection? St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 6 In compliance with requirements of the last inspection, the home has improved recording systems. Pre-set valves have been fitted to hot water outlets accessed by residents to ensure the delivery of hot water is controlled. Feedback from residents suggests that the choice and quality of food available at St Margaret’ s has also improved. 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 DS0000046888.V255906.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 DS0000046888.V255906.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&2 Residents benefit from accessible information that outlines the rights and responsibilities attached to a placement at St Margaret’s. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place and the Manager confirmed that copies are made available to both current and prospective residents. These documents provide accessible information about the services offered at St Margaret’s. It was however identified that neither documents had been recently updated. It is therefore required that this is addressed and that information such as; the qualifications of current staff be included. A written contract is in place which outlines the terms and conditions attached to a placement at St Margaret’s. Each resident has been given a copy of the contract and a signed copy is also retained by the home. St Margarets DS0000046888.V255906.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 Residents benefit from the provision of appropriate and respectful support with their health and personal care needs. Residents would be further protected by being included in the regular review of their care plans. EVIDENCE: There was documentary evidence that each resident has a plan of care which provides detailed information about their strengths and needs. The care plans were well maintained and easy to use. In line with a requirement of the last inspection, the Manager has been undertaking reviews of the care plans, involving the resident and next of kin, where appropriate. The Manager reported that at the time of the inspection, approximately half of care plans had been updated in this way. It is therefore required that the home continue this process to ensure all residents have been fully involved in the developing and reviewing of their care plans. In addition to these formal reviews, the Manager confirmed that she and her Deputy, review the accuracy of care plans on a monthly basis. Evidence of this St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 10 review was not available and therefore it is required that a way of recording this activity be introduced. All residents spoken with confirmed that staff provided their care with dignity and respect. Several residents attend regular healthcare appointments and the home fully supports residents to attend these visits. The storage and recording of medication was inspected and found to be satisfactorily maintained. It was however noted that some homely remedies in the medication cupboard were outside the expiry date and therefore an Immediate Requirement was made that these medicines be returned to the Pharmacy and all medication be thoroughly checked. The Manager confirmed that only staff who had received relevant training handled medication and there were certificates in place to reflect this. Various policies for managing medicines were included at the front of recording sheets, so staff could refer to them easily. Risk assessments are in place to assess whether residents are able to take responsibility for their own medication. In compliance with the requirements of the last inspection, these risk assessments are now reviewed at regular intervals, or where a residents’ needs have changed. St Margarets DS0000046888.V255906.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): 12, 14 & 15 Residents are supported and encouraged to lead healthy and fulfilling lives. EVIDENCE: The inspection took place at the beginning of the Christmas period and a number of special events had been organised to celebrate the festive season. During the afternoon of the inspection, a singer provided a concert in the lounge which was observed to be a thoroughly enjoyable event. A carol concert had also been arranged for later that week and posters around the home informed residents of this activity. Residents confirmed that a ‘care dog’ continues to come into the home each week and residents and staff spoke positively about this activity. Some residents informed the Inspector that they go out independently and meet up with friends for meals and drinks out. The Manager informed the Inspector that opportunities to take other residents out had been made available, but that residents rarely accepted the offer of an outing when presented to them. St Margaret’s continues to operate an open door policy for relatives and friends to visit. During the inspection, several visitors were noted being greeted and welcomed by staff as they popped in for tea. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 12 As highlighted at the last inspection, meals have been the subject of much debate at St Margaret’s over recent months. Since the last inspection, the home has employed a new Chef. This person is highly qualified and has worked with the residents to produce menus that are acceptable to them. The Inspector spoke with five residents about the food provided. With the exception of one person, all now expressed satisfaction with the food provided at the home. A Christmas menu had been produced and this was referred to by one resident as, “looking wonderful”. Discussion with the Chef confirmed that menus are compiled on the basis of feedback from the residents. One resident in particular, has been meeting regularly with the Chef on an individual basis to discuss and plan menus. The Chef stated that the budget available to him is sufficient to provide good quality homemade food, using fresh ingredients. The meal served of steak and kidney pie, mash potato and fresh vegetables was well presented and appetising. Staff confirmed that a vegetarian option is always available, as is an alternative for anyone on a special diet. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 13 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): These standards were not inspected on this occasion, please refer to inspection report from the unannounced inspection carried out on 07 June 2005. EVIDENCE: St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 14 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, 25 & 26 Residents benefit from an attractive, spacious and clean environment. Residents would be better protected if the outstanding health and safety matters were addressed. EVIDENCE: The findings below were based on the Inspector touring the building and talking to residents and staff. St Margaret’s is a three-storey, Grade 2 listed building situated in a quiet residential area of Eastbourne. The home is located in close proximity to local amenities and the seafront. Décor is satisfactory throughout the home. Resident accommodation is provided in sixteen single bedrooms and three shared bedrooms. All residents who share have expressed a positive wish to do. Many of the bedrooms provide ensuite facilities. The home offers a range of communal areas, including a large and attractive dining room, a lounge, landing and reception area. A large and wellSt Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 15 maintained garden is situated to the rear of the property. Parking is available at the front of the home. The home has a series of stair lifts which provide access to all three floors. The majority of the residents at St Margaret’s use the stair lifts independently. The home has not been assessed by a suitably qualified person to ensure that the environmental adaptations are sufficient to meet the needs of the people living at St Margaret’s. It is recommended that this be carried out. Communal bathrooms and toilets are appropriately situated on each floor. Bathrooms are fitted with electronic bath seats to enable residents to bathe safely with support. Residents spoke positively about the upkeep of the home and all spoken with felt the home provided a ‘lovely environment’ to live in. There continues however, to be a number of outstanding requirements since the home was purchased that several issues of health and safety be rectified. It is acknowledged that the Providers have complied with some of the previous requirements, but it is unacceptable that eleven windows still remain unrestricted and that many fire doors, were again found to be propped open. Following the last inspection in June 2005, a letter of Serious Concern about these matters was sent to the Responsible Individual. This person telephoned the CSCI to state the action that would be taken to meet the requirements, but never formalised this plan of action nor indeed took steps to ensure compliance. The CSCI will now take action outside the inspection process to ensure these requirements are met. Due to the layout of the home, there is not a separate laundry for the cleaning of residents’ clothes. Washing machines and tumble driers are located in a conservatory area, situated off the main lounge. Sluicing facilities are not currently available in the home and it is recommended that this is a consideration for the future. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Residents benefit from a committed team of staff who receive training relevant to the work they perform. Residents would be better protected if correct recruitment procedures were followed at all times. EVIDENCE: On the day of inspection, fifteen residents were living at St Margaret’s. There were three carers on duty, the Manager and additional domestic and kitchen staff. The rota indicated that these staffing levels were typical. The Manager confirmed that staffing levels were adequate to meet the needs of the residents and that the home was considered to be fully staffed. Staff receive training relevant to the work they perform. At the time of the inspection three staff had completed National Vocational Qualification (NVQ) Level 2 and a further two are reported to be near completion of this training. Four staff are undertaking an induction in line with Skills for Care. Staff have also recently undertaken training in handling medication and fire safety. The recruitment files of two new staff members were examined. It was identified that a second reference for one of these people had not been obtained prior to them commencing employment. This was discussed with the Manager who stated that they had had difficulty in obtaining this reference in writing. The Manager was advised that a second reference must be obtained as a matter of priority and that in future people must not commence working St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 17 without the correct checks being in place first. The home is also required to ensure that recruitment files contain written evidence where POVA First checks have been conducted and that the home has a recent photograph of all staff. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 18 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, 32, 33, 35 & 38 Residents benefit from living in a well-managed home. Residents are protected by the systems in place to support them with their financial affairs. The identified issues of safety must be improved for the protection of all residents. EVIDENCE: The Registered Manager is a skilled and competent practitioner who is qualified as a Registered Nurse and is the process of completing the Registered Managers’ Award. The staff spoken with commented that the Manager was approachable and that they felt well supported by her. The home holds residents’ and staff meetings and an annual questionnaire is sent out to residents and their relatives to gain feedback about the home. At St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 19 the current time, the Registered Provider is not carrying out monthly monitoring visits in accordance with Regulation 26 of the Care Homes Regulations 2001. This has not previously been required as the Providers were frequently in the home. As this is no longer the case however, the Providers are required to produce these reports and supply copies to the Commission each month. In line with a requirement from the last inspection, the home has introduced a formalised system for the management of monies held on behalf of the residents. Individual lockable tins are now in place for each resident and a system of recording transactions and maintaining receipts is in place. It was noted that the money in one tin did not correspond with balance listed on the recording sheet. It is probable that this is simply a calculation error and therefore the home must ensure that tins and balances are regularly checked for accuracy. There has been an outstanding requirement since the home was purchased that a number of health and safety issues are rectified. The Providers have addressed some of these areas and as such radiators are now fitted with guards and hot water outlets are temperature controlled. It was however, disappointing to note that twelve windows still remain unrestricted. A rolling programme has been in place to address this, but again this has not been completed within the timescales agreed. As identified in the Environment section of this report, this matter will now be addressed with the Provider outside the inspection process. It was also again noted throughout the inspection, that a number of fire doors were propped open and as discussed at previous inspections, this practice cannot be allowed to continue and another immediate requirement was issued. A further monitoring visit with the Fire Brigade will be conducted to ensure the home takes steps to comply with fire safety regulations. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 20 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 2 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 X X 2 St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 21 YES 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 2 Standard OP1 OP7 Regulation 4&5 15 Requirement That the Statement of Purpose and Service User Guide are updated. Care plans should be regularly reviewed and updated to reflect changing needs. All entries to be signed and dated. (Previous timescale of 01 August 2005 not met) Risk assessments to be carried out in respect of all areas of residents lives. Risk assessments should be regularly reviewed and updated, particularly as change in needs are identified. (Previous of timescale of 01 August 2005 not met) That all medication is within date. The home follow correct recruitment procedures to ensure the safety and protection of service users. That the Registered Provider conduct unannounced monitoring visits in accordance with Regulation 26 and reports are sent to the CSCI each month. DS0000046888.V255906.R01.S.doc Timescale for action 01/02/06 01/04/06 3 OP7 13(4) 01/04/05 4 5 OP9 OP29 13(2) 19& Sch 2 as amended 26 13/12/05 20/12/05 6 OP33 01/03/06 St Margarets Version 5.0 Page 22 7 OP35 16(2)(l) 8 OP38 13(4)(a) 9 OP38 23(4) That the home ensure that an accurate record of money held on behalf of service users is maintained. All windows that are above ground level to be restricted. (Previous timescales of 01 January 2004, 01 November 2004, 01 April 2004 and 07 June 2005 not met) The home review its practice of propping open fire doors and consult with the Fire Brigade for guidance. (Previous timescale of 19 January 2005 and 07 June 2005 not met) 10/01/06 13/12/05 13/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP22 OP26 Good Practice Recommendations The layout of the home is assessed by a suitably qualified person. The home consider the need for future sluicing facilities. St Margarets DS0000046888.V255906.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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