Inspection on 16/07/07 for St Margarets

This inspection was carried out on 16th July 2007.

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 07/01/09

St Margarets 11/07/08

St Margarets 02/08/06

St Margarets 31/10/05

St Margarets 03/06/05

St Margarets 12/01/05

St Margarets 14/06/04

St Margarets 16/02/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE St Margarets 22 Aldermans Drive Peterborough PE3 6AR Lead Inspector Don Traylen Key Unannounced Inspection 16th July 2007 14:30 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 DS0000015187.V343038.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.V343038.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.V343038.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 2nd August 2006 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.V343038.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit by one inspector over 4.5 hours on the afternoon of Tuesday 17th July 2007. A tour of the building was undertaken and three care staff and the manager were present during the inspection. A visiting NVQ assessor who was assessing care staff for their awards at the time of the inspection was spoken to. There were 15 people living at the home on the day of inspection. What the service does well: What has improved since the last inspection? The manager has trained to be a Key Practitioner in protecting Vulnerable Adults from Abuse. This training has been provided by Cambridgeshire County Council. Staff training has continued to be provided to all staff and more care assistants were undertaking NVQ level 2 and level 3 awards in care. The manager has completed her Registered Managers Award and has recently found funding to allow her to complete the NVQ level 4 award in care. External and internal improvements to the building have been undertaken and were ongoing at the time if this inspection. The manager has been provided with a computer and at the time of this inspection she was awaiting an internet connection. She stated that she would be able to have quicker access in the future to legal and other important guidance offered by the CSCI the Primary Care Trust and the Department of Health. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 6 What they could do better: • The home’s medication policy must include procedures to administer PRN medication and to specifically include the criteria and instruction that should be applied when judging if PRN medication is administered. A more rigorous recruitment policy must adhered to, so that recruitment procedures are clearly understood and conform to The Care Homes Regulations 2001. Temperatures of fridges and freezers must be accurately recorded so that people are not at risk of contaminated food. • • 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.V343038.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.V343038.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): 3,6, Quality in this outcome area is good. People are assured of a comprehensive assessment before they move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two peoples’ assessments were read that had been obtained from PCT Care Managers prior to people moving into the home. The manager had also carried out assessments for these two persons. There was sufficient information contained in these documents to provide a detailed care plan. Intermediate care is not provided. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, Quality in this outcome area is good. People who use the service are assured of well-planned care and kind and attentive support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained comprehensive care tasks. They included records of weights, daily activity, visits by health services consent for administering medication as well as basic functions of personal care giving. There was one example of very good care having been provided to a terminally ill person who chose to remain living at the home. The person was supported by District Nurses, a GP and the Peterborough PCT support service (Peterborough PMS, that provides a support service for care homes in Peterborough area. A letter of support from a District Nurse was addressed to the home congratulating the home for their excellent and attentive care they were able to provide for one person living at the home. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 10 Observations were made of the manner in which the manager and care staff were showing their considerate and kind approach to helping people. Medication records were read and had been accurately recorded on Medication Administration Record sheets. There was not a policy for the management and administering of PRN prescribed medication and this has been made requirement in this report. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is good. People who use the service are assured the home matches their expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records kept of the meals provided were of a balanced nutritious variety. Mostly a traditional British meal of meat and two vegetables were chosen by people living in the home. The meals are planned and varied over a four weekly rotation. Six of the six people who were asked said they enjoyed their meals and were offered choices of what to eat and where they preferred to eat. They each stated they would raise any concerns with the manager if they wished to. One family was kept informed and included in the care arrangements made by the home and community Health Services when one person was ill and who wanted his family to be informed. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, Quality in this outcome area is good. People are safeguarded by the policies and procedures adopted for their protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaint book and a book containing details of the one case of suspected abuse that was reported by the home have been maintained. The manger is a recognised Key Practitioner in protecting Vulnerable Adults from Abuse and was trained by Cambridgeshire County Council. The manager has developed an awareness of good practices of protection. Two allegation of abuse have been appropriately managed and were reported by the home. The manager has encouraged and arranged training with the local authority for all staff in adult abuse. However, as a Key Practitioner and in relation to the comments made under the outcome section entitled, “Staffing”, in this report, she should have done more to ensure that the homes recruitment process was compliant with The Care Homes Regulations 2001 and was designed to assure protection for people living in the home. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26, Quality in this outcome area is good. People live is homely surroundings that are safe and reasonably maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is warm and comfortably furnished. Because of the age of the property it is in need of greater maintenance than a recently built home. There are some areas and fittings that are worn and in need of replacement and maintenance, such as the kitchen floor; some armchairs and furnishings and areas of paintwork. Some of the carpets had been replaced and some areas of the home had been re-decorated. The manager said there is a plan to replace more carpets and pieces of furniture and to redecorate in stages as necessary. She described the improvements that were being undertaken to the front exterior of the home. She showed me where the new wall was being built and the trees that had been pruned to allow more daylight into the front rooms. She stated that new replacement windows had been purchased and are ready St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 14 to install, after the exterior work has been completed. The manager keeps a file of the general maintenance work that is required and this is given to the registered providers to attend to. The home uses one or two of the vacant rooms as storage areas. Some hoisting equipment or wheelchairs are stored in various places on each of the three floors. Rooms are personalised and were seen to be comfortable and appeared ‘cosy’. Three people stated their rooms were to their liking. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, Quality in this outcome area is adequate. People who live in the home are not consistently safeguarded by the home’s recruitment procedures but are adequately safeguarded by appropriately trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The file of one care assistant, employed since the last inspection on 02/08/2006, was read. The person commenced employment on 1st September 2006 but the CRB disclosure was dated 20th February 2007. There was no record of the CRB application and no POVA First check recorded. Induction training was satisfactory and a range of certificates showed that a appropriate training had been provided for this person. There was not a record of any supervision arrangements in place for this person that should have been arranged when he was working without a CRB disclosure. It is judged that an unsafe recruitment practice had taken place because the CRB disclosure was not obtained until five months after commencing employment. Neither was there a letter of confirmation of employment to say whether the appointment was subject to a satisfactory CRB disclosure. Training provided for care staff was comprehensive and covered appropriate subjects. Training for all staff included: infection control; food safety hygiene; Protection of Vulnerable Adults. NVQ level 2 awards were either achieved or being completed for 7 staff and three staff have started NVQ level 3 awards. A St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 16 basic in-house Induction training programme has been established. The manager has maintained her efforts to find and arranged a range of training for the care staff employed at the home. Three care staff plus the manager work am and two care staff and the manager work during the afternoons. Only one care worker is present between 9.30pm and 8 am, but is supported by an on-call member of staff who would attend at short notice if necessary. This was discussed and the manager considered arranging for a care worker to start work at 7am. At the time of inspection there were 15 people living in the home. St Margarets DS0000015187.V343038.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): 31,33,35,36,38, Quality in this outcome area is adequate. Peoples’ best interests are generally promoted although some aspects of management do not completely demonstrate this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has completed her Registered Managers Award and is undertaking the NVQ level 4 award in Care and has recently been funded to start this coursework in September 2007. The manager leads staff by setting an example that is thoughtful of people living in the home. Her attitude and communication with people living in the home and towards staff were observed to be respectful and kind. She sets a clear example of good care practices for staff to follow. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 18 Fire alarms are tested weekly as are emergency lights tested weekly. Fire drill have been practiced by staff. Fire Officer last visited in 2005. Records of meals and temperatures of cooked meat are recorded. Temperatures of the fridges and freezers had been recorded, but the information did not relate to the temperature indicated by thermometers but to the dials for the temperature controls on the front of the freezers. The manager later found the thermometers to use and agreed these would be used to read the temperatures of the fridges and freezers in the future and that each appliance would be identified by a number. Written transactions were kept for all service users expenditures. It was judged and referred to in section relating to staffing outcomes that an unsafe and less than adequate recruitment practice had taken place. The recruitment policy was dated 2003 although the AQAA stated it had been reviewed in September 2006. There was a lack of any recorded monitoring of care staff, although the manager stated she observes and assesses care assistants competencies on a daily basis because she has close and regular contact with care assistants. The manager stated that supervision is used as a system to monitor staff. St Margarets DS0000015187.V343038.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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 St Margarets DS0000015187.V343038.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 OP9 Regulation 13(2) Requirement Timescale for action 01/09/07 2 OP29 19(5)(d), & Schedule 2 16(2)(g) 3 OP38 The home must write a policy that refers to the administration of PRN prescribed medication, so that staff are clear of their responsibilities and instructions to administer PRN medication and to ensure that people who live in the home are not at risk and will be assured of the safe administration of their prescribed medication. The home must ensure that a 01/09/07 POVA First clearance is obtained before a new employee works in the home, so that people who live in the home are assured of the fitness of care workers. Temperatures of fridges and 01/09/07 freezers must be accurately recorded so that people are not at risk of contaminated food. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 21 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 OP27 OP33 Good Practice Recommendations It is recommended that the home consider arranging for a care assistant to start work earlier, so that at least two care assistants are working in the home from 7am. Any monitoring undertaken should be recorded so that it may be used as evidence of the home’s improvement. St Margarets DS0000015187.V343038.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cambridgeshire Area 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.V343038.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!