Inspection on 19/07/06 for St Margarets

This inspection was carried out on 19th July 2006.

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

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

Other inspections for this house

St Margarets 18/07/08

St Margarets 10/01/06

St Margarets 21/06/05

St Margarets 06/12/04

St Margarets 17/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE St Margarets 17 Brookvale Road Highfield Southampton Hampshire SO17 IPW Lead Inspector Ms Jan Everitt Unannounced Inspection 19 July 2006 09:30 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 DS0000011792.V291648.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 DS0000011792.V291648.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margarets Address 17 Brookvale Road Highfield Southampton Hampshire SO17 IPW 023 8058 4877 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Thorne Mrs Thorne Mrs J Francis Care Home 18 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (18), Mental disorder, excluding learning of places disability or dementia (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (18), Old age, not falling within any other category (18), Physical disability (4) St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users in the DE and MD categories must be at least 55 years of age A total of four service users may be accommodated between the ages of 55 and 64 A maximum of four services users may be accommodated at any one time in the PD (E) category 10th January 2006 Date of last inspection Brief Description of the Service: St Margaret’s is a care home situated in Highfield, Southampton. The home is registered to provide care to eighteen service users within the categories of old age. The home also accommodates service users who have a physical disability, dementia, mental health issues and four service users over the age of 55. This has been agreed part of the conditions of registration. The home is a large detached property and comprises of accommodation in both single and double bedrooms arranged over two floors. The home also has two lounges, a dining room and a smoking room situated on the ground floor. The home has a stair lift, which enables service users to access both floors of the home. To the rear of the property is a car parking area and to the front of the property is a large well-maintained and pleasant garden. The home is situated close to local facilities and is a short journey away from Southampton. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to St Margaret’s residential care home, which was unannounced, took place on the 19th July 2006 and was attended by one inspector. The visit to St Margaret’s formed part of the process of the inspection of this service to measure the service against the twenty key national minimum standards for the year 2006/7. The focus of this visit was to support the information gathered prior to the visit and to monitor the service’s improvement over the previous two inspection visits. The judgements made in this report were made from information gathered prior to the visit; pre-inspection information submitted to the commission by the registered manager, information from the previous two reports, the service history correspondence and contact sheets appertaining to the service were also taken into consideration. A number of comment survey cards were sent to relatives prior to the visit of which eleven were returned. They all reported a high level of satisfaction about the care and services delivered to their relative. Thirteen service users comment cards were also received prior to the visit and these were taken into consideration when formulating the judgements and the report. Four care staff comment cards were also returned and they all recorded to have job satisfaction and felt very supported by the manager. Four visiting professionals commented on the home as having a well trained and cooperative staff group who cared for their clients to a high standard. Further evidence was gathered at the site visit. The inspector toured the building with the manager and spoke with a number of the residents and staff and also viewed a sample of records. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that staff undertake training to enable them to fully understand the needs of those service users with dementia and mental health problems and other specific conditions that exist in the home. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 7 Weights should be recorded on admission to the home to give staff a benchmark to judge whether a service user should be nutritionally risk assessed and a care plan put in place. Records of interviews undertaken by the manager should be recorded as part of the recruitment process. An environmental risk assessment should be recorded as part of the health and safety process of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 9 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): 3 Standard 6 is not applicable to this service. The quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service and viewing records. The needs of the service users admitted to the home are met. EVIDENCE: A sample of four service user pre-admission assessments was viewed. The assessment tool is comprehensive in content. The manager visits the service users in their own homes, or potential service users about to leave hospital and reports to gain information from the nursing staff. The manager reports that usually service user’s relatives are involved with the admission. This was confirmed by the comments made in the survey returns. Thirteen service user comment cards were received prior to the visit. Three indicated that they had visited the home before admission and one had spent a whole day in the home before making decisions. Relative comment cards indicate that they were involved with the admission and are satisfied with the service provided in the home. . St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service and viewing records. The care plans and risk assessments are detailed and outline how the care should be delivered. The health needs of the service users are assessed and met. Service users are protected by the home’s policies and procedures for the management of service users medication. Service users’ rights to privacy are upheld. EVIDENCE: The inspector audited a sample of four service user care plans. These were found to contain relevant information as stated on Schedule 3 of the Care Home Regulations, care planning information, risk assessments, health care professionals involvement where necessary and guidance for moving and handling for those service users who needed assistance with mobilisation. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 11 The inspector observed that the home did not undertake a nutritional assessment on admission to the home and admission weights were not recorded. However, all service users are weighed at least monthly and more frequently if it is recorded they are losing weight. The manager reported that supplement drinks are prescribed for those referred to the GP with poor appetite. The care plans are reviewed monthly and the manager reported that she and her deputy reassess and review all the planned care yearly. Risk assessments were in place for the use of bedrails and there was evidence that the use of them had been discussed with service user’s relatives. Owing to the mental frailty of most of the service users it was difficult to establish their level of involvement with the care planning process but those spoken to were very happy about living in the home. All of the service users are afforded access to relevant health care professionals and service users are registered with the local GP of their choice. The home has the services of several GPs and whilst at the home the inspector overheard a conversation with the GP surgery and it was obvious the manager has a good working relationship with them. The manager reports that the GPs will review the service users every three months. The inspector received four comment cards from visiting professionals. The district nurse, the chiropodist, the community psychiatric nurse and the continence advisor. All report they consider the care given in the home is good and appropriate and staff show kindness, consideration and they are well trained and competent. Another comment was that staff are helpful and have good knowledge of their residents. The inspector also overheard the manager discussing a medication review with the memory nurse and was attempting to coordinate a change in prescription. She demonstrated a good working relationship with the nurse and a good understanding of the resident’s condition. The inspector observed that pressure-relieving cushions were in place and one service user had the use of a pressure-relieving mattress loaned to them by the equipment store. The chiropodist, dentist and optician visit the home regularly or when necessary. The home administers medication via the blister pack system that the manager reports is good. The inspector audited a sample of the MAR sheets and they were recorded appropriately. The inspector observed a carer ensuring that one service user’s medication for Parkinson’s disease was administered on time as prescribed. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 12 The medication is stored in a safe place and the home was not administering any controlled drugs at the time of this inspection. The home can demonstrate that the policies and procedures for ordering, receiving, storing, administration and return of unwanted medication are followed. At the time of this visit no service users were choosing to self-medicate. The supplying pharmacist visits the home monthly or on request. Staff have received training in the safe handling of medication from a local college and the manager reports that she is about to send a further three staff to this training. The service users spoken to confirmed that the staff were ‘good to them’. The inspector observed staff knocking on doors and generally treating the residents courteously and with respect. A comment received from a staff member quoted ‘I would like to be treated with the respect from clients that I myself treat them with’. Service users confirmed that they receive personal care in the privacy of their room and in the rooms that are shared there was evidence of a screen to ensure privacy for both service users. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 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 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service. The home does provide activities but they are not planned and programmed in advance. However, the activities that do take place, meet the needs of the service users in residence. Service users are supported to choose with whom they have contact with and receive visitors as and when they wish. Service users are supported, if necessary, to access to the community. Service users are able to make choices as to how they wish to live their lives in the home. Service users confirmed that the home provides a varied menu of their choice. EVIDENCE: The home has no formal activities programme advertised in the home. The activities take place on a day-to-day basis depending on what the service users choose to do. The manager reports that most of the service user’s St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 14 mental capacity would not allow them to participate in quizzes or group games. One of the service users was observed to be enjoying music and although she could not relate to the inspector, her pleasure in listening to music was apparent. The manager reported she has a large collection of CDs and that these are played in the lounge frequently as the other service users enjoy listening to the music also. The care plans evidenced service user’s preferences and social histories are recorded when appropriate. The manager reported it is difficult to obtain information about social histories from some of the clients as there are no relatives involved and information is dependant on what the service user wishes to share with the home. The home has requested that the families involved provide the service user with a memory book which could be comprised of photographs and items to stimulate memory. The manager reports that she has little response from the families in supplying these. The comments received from the service users indicated that there are activities arranged in the home such as bingo, video, sing-a-longs and reading with the carers. The manager reports that the service users in residence at the present time enjoy music, the sing-a-longs and sitting chatting on a oneto-one basis. Some of the other service users commented that they enjoy their own company and are happy not to join in the activities. The manager informed the inspector that quite a number of service users enjoy sitting in the garden area watching the people go by. On the day of the visit the weather was too hot for residents to venture out and the manager was overheard saying to them to stay in the cool. Staff were observed to be sitting with service users talking to them. The Roman Catholic Church does attend the home monthly to see one service user. The home has no visiting restrictions and the comment cards received from the relatives indicated that they are made welcome at the home and can see the relative in private. The visitor’s book was observed to be regularly completed by all visitors. The manager reported that the service users in residence at the present time are unable to manage their own financial affairs. The inspector observed on the tour of the home that rooms were very personalised and some residents are able to bring with them personal items of their choice including pieces of furniture. The inspector observed in the care plans an inventory of items that service users brought into the home on their admission. The service users spoken with reported that they could do as they wish through the day and the inspector observed them mobilising freely around the home. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 15 A two-week menu plan was included in the pre-inspection documentation sent by the manager. The menus viewed were nutritious and wholesome. On the day of the visit the menu had been changed because of the extremely hot weather and a more appropriate menu was offered. The food logbook records what the service users have eaten and if service users choose an alternative menu this is logged also. The chef caters for one diet controlled diabetic resident. The inspector observed the lunchtime meal being served. The meal was well presented and looked wholesome and service users were observed to be enjoying their meal. Service users spoken to report that they enjoy the food. The cook has been in post for a considerable amount of years and she cooks for the residents as though it was for a large family and organises the kitchen and the staff serving the meals in a systematic way. The kitchen was clean and has been redesigned to be more conducive to a busy working environment. The service users do not have a nutritional risk assessment undertaken on them on admission but all service users are weighed two weekly and more frequently if there is any weight loss or excessive weight gain. The environmental health officer visited the home in October 2005 and the manager submitted to the inspector a copy of the letter the manager wrote in reply to the report stating that the recommendations made had been adhered to. All staff have undertaken the food handling and hygiene course. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 16 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 quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service. Service users are aware how to make a complaint and to whom. The home has procedures and practices in the home to protect service users from abuse. EVIDENCE: The home has a complaints procedure that is displayed on the wall and can be found in service users’ bedrooms. Comment cards received from service users and relatives state that they would speak to the home’s manager if they had any concerns. The manager reports that she would take advice from care managers should there be a complaint that could not be resolved. Neither the home nor the commission have received any complaints since the last inspection. The complaints log was viewed by the inspector, which demonstrated that no complaints had been recorded. The home has an adult protection policy and procedure. All staff have received training in adult protection as part of their induction course. Staff spoken with and the survey comment cards returned confirmed that staff are aware of the procedure and that they would speak to the manager and document any relevant information. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 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 quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely well-maintained environment. The home is clean and hygienic. EVIDENCE: The inspector toured the home with the registered manager. The home was very clean and homely and suitable for the service users in residence. The home has undergone a vast amount of redecoration and refurbishment over the past year. A new bathroom has been created downstairs and three further bedrooms have been redecorated. The manager reported that the next year’s plan is for the laundry to be refitted and decorated, although the machines in use will be retained as they are fit for purpose. The side and front garden are accessible to users and have seating areas for service users to enjoy the fairer weather. The manager reports that St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 18 unfortunately the umbrellas and flower containers are regularly stolen from this front area which is upsetting as the manager takes pride in the other areas of the garden which, at the time of the visit, were well kept and a picture of colour. The home has a maintenance programme and repairs are carried out as and when necessary. The home has not undertaken risk assessments of the environment. This was discussed with the manager and will be audited at the next visit. The fire risk assessment was planned to be undertaken by a fire officer in early August. The home is clean and hygienic and no offensive odours could be detected. Comments from service users were ‘the girls are always making sure the home is clean and they work hard’. ‘The home could not be cleaner’. ‘The home is never dirty or smelly’. ‘Staff are always keeping on top of the general appearance’. Service users relatives reported in comment cards that they considered the home to be clean. ‘I have found the home clean, tidy and comfortable and my sister is happy and well cared for’. The home has an infection control policy. Staff have received training in infection control and are aware of the policy. Gloves and aprons are supplied to staff to aid the control of infection. The home employs a separate staff group to undertake the cleaning daily. Washing machines were observed to have a sluicing facility programme and the home has a waste disposal contract for the disposal of clinical waste. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 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 quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service and viewing records. The home had adequate staff on duty that were found to be trained and competent to do their jobs. Service users are in safe hands, however, the home is working towards implementing a training package that will include service specific issues. Service users are protected by the home’ recruitment policies and practices. EVIDENCE: On the day of this visit there were sixteen service users in residence. There were three staff members on duty plus the manager. The staff rota confirmed that weekdays the home is covered by four staff in the a.m. shift and two on the p.m. shift. Week-ends are covered with three care staff a.m. and two p.m., and at night one waking staff and one sleeping staff member. The home employs a separate person to undertake the general cleaning and housekeeping of the home. The pre inspection document states that six of the ten staff have achieved their NVQ level 2 in care. The manager reported that one staff member is enrolling and a further three are undertaking their NVQ level 3. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 20 Staff spoken with at the time of the visit and those who returned the survey comments cards stated that they have undertaken their NVQ training or have the opportunity of doing so. The previous two reports have identified shortfalls in obtaining relevant documentation during the recruitment process, but the inspector viewed a sample of four recruitment files at this visit, two of which have been relatively recent recruits. All documentation stated on Schedule 2 of the Care Homes Regulations was present. A recommendation will be made that the manager, who undertakes all the recruitment of staff, records detailed interview notes. The manager is committed to training the staff and all new staff will now undertake the skills for care induction programme. She has also recruited a local college to design a training package to meet the staff’s training needs to include service specific training appertaining to the care of the service users, such as mental health training, dementia and Parkinson’s disease. This programme has yet to be implemented. The need for staff training for service specific needs has been discussed in the two previous reports and was a requirement of the report of June2005 and will be a requirement from this report. The staff’s training needs are identified through appraisal but a training matrix is not available and training records are maintained in personnel files. The manager reports that she is awaiting to meet with the training manager so that she can discuss and assess what each carer’s training needs are. The care workers survey received by the inspector indicated that the staff do receive training that is fully funded by the provider. The training the staff stated was available to them was NVQ level 2 and 3, fire training, moving and handling, first aid training, safe handling of medication. This would indicate that service specific training has yet to be undertaken but the manager is working towards a whole new training package for staff. Staff also indicated that they are satisfied with the training and support they receive from the manager. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 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, 36 & 38 The quality outcome of this area is good. This judgement has been made using available evidence including a visit to this service, viewing records and speaking to staff. Service users live in a home that is run and managed by a person who is fit to be in charge and is able to discharge her responsibilities fully. The home is in the process of creating a quality assurance system to measure the quality of the service against the statement of purpose. The home supports service users to ensure their financial interests are safeguarded. Staff are appropriately supervised. The health, safety and welfare of service users and staff are promoted and protected. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has been in post for twenty-six years and is the daughter of the provider. The service users and relative comment cards reported some very complimentary comments about the home manager and says she is always present in the home and is available to talk to. The inspector observed that the manager was very familiar with residents needs and sat and spoke to a number individually throughout the day. The manager is in the process of undertaking her Registered Manager’s Award and anticipates it to be completed by September 06. The manager has undertaken regular updates in mandatory training and undertakes the training of the staff in mandatory health and safety issues. The manager has no specialist expertise or training in the care of the client group the home is registered to care for, but her years of experience allows her to understand the complex needs of the user group. She reports that the community psychiatric nurse attends the home regularly to support the staff with a number of service users and shares knowledge on how to care for the clients with more complex mental health needs. The report of June 05 stated that there was no formal quality assurance system in place to measure the success of the service. The manager showed the inspector an example of a questionnaire that she intends to distribute to relatives and service users, which would give opportunity for relatives/service users to comment on a variety of issues that underpin the service. Regulation 26 reports are received at the CSCI on a frequent basis from the provider’s representative and these are usually positive reports. Comments from service users and comments taken from the survey sent by the commission would indicate that there is a high level of satisfaction with the care and services delivered at the home. Comments from visiting professionals were complimentary and are quoted as ‘the staff show kindness and consideration and are well trained and competent’, ‘ staff provide excellent care and help to prevent hospital admission for as long as possible’. A social worker commented that ‘I have found the staff helpful about the client’s needs and staff interact well with the service users’. Relatives comment state ‘staff are brilliant and are very knowledgeable and keep me informed of any changes’. ‘The family and I are very satisfied with the care mum receives and am always informed about everything’. ‘My brother always tells me he is very well and perfectly content at the home’. The manager has a comment and suggestion book on display and a notice invites relatives/visitors to record comments. The inspector viewed this book. The content of the comments in the book stated high praise for the home and the staff and manager. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 23 Although the home at present has no formalised quality assurance system the comments recorded in the book and comment survey received back from service users and relatives would indicate that the service meets the needs of the residents and that there is a high level of satisfaction throughout the service. However, the manager must distribute the questionnaires to the appropriate people to obtain feedback about the service and use this information to develop an action plan to improve and maintain standards. The manager does an annual audit and review of all care plans. The home does not directly get involved with the management of service user finances. The manager described how she would support service users to receive their financial entitlements through liaising with appointees and family members. Relatives generally arrange for the purchase of clothes or any other items for service users. The manager showed the inspector the staff supervision records. These record the date and length of time the supervision took, and the topics discussed. The manager commented that she spends time on a daily basis and is continually undertaking informal supervision by observing practices. This was confirmed by a member of care staff and also the care staff surveys reported that supervision is planned and is undertaken on a one-to-one basis\ and also that all staff meet weekly to discuss any issues that have arisen. The staff report that the manager is very supportive of them and works with them regularly. A sample of servicing certificates for equipment and systems were viewed by the inspector and found to be current. The home maintains records of all checks on fire equipment. A fire officer is undertaking the fire risk assessment in August 06. The manager could not demonstrate an environmental risk assessment and reported that she risk assesses the environment daily but that nothing is documented. This will be a recommendation of this report. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 24 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 3 10 3 11 X 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 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 3 X 3 St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 25 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 OP30 Regulation Reg 18(1)c(i) Requirement Staff must undertake training in service specific issues to enable them to understand the needs of the service user category. Timescale for action 30/11/06 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. 3. Refer to Standard OP7 OP29 OP38 Good Practice Recommendations It is recommended that service users’ weights be recorded on admission to the home to adequately assess needs and risks. It is recommended that the manager maintain records of staff interviews. It is recommended that an environmental risk assessment be undertaken and reviewed annually. St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margarets DS0000011792.V291648.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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