Inspection on 03/06/05 for St Margarets

This inspection was carried out on 3rd June 2005.

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

The inspector 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 07/01/09

St Margarets 11/07/08

St Margarets 16/07/07

St Margarets 02/08/06

St Margarets 31/10/05

St Margarets 12/01/05

St Margarets 14/06/04

St Margarets 16/02/04

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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 Announced 03 June 2005 @ 10:00 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service St Margarets Address 22 Aldermans Drive Peterborough PE3 6AR Telephone number Fax number Email 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 01733 567961 Mr Riaz Mawani and Mrs Saida Mawani Kathleen Gregson Care Home 15 Category(ies) of Old age not falling into any other category (OP) registration, with number 14, of places Learning Disability (LD) 1, St Margarets Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 client with LD Date of last inspection 12-01-2005 Brief Description of the Service: St Margarets 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 Margaret’s is a three story, semi-detached property that has been adapted 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 has successfully created a “homely” atmosphere an objective that is clearly proclaimed in their Statement of Purpose. St Margarets Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager and one of the registered providers were both available throughout the inspection. The inspector asked 9 service users and 2 staff for their views about living and working in the home. 14 service users comment cards were completed with the help of care staff although no actual comments had been recorded. 8 relatives/visitors cards were completed and two positive comments were made and one negative comment was recorded. What the service does well: What has improved since the last inspection? 4 of the 5 Requirements made at the last inspection report have been met. New carpets to the stairs have been laid and the stairway has been redecorated. Care Plans have steadily improved in their content and presentation over the past year. St Margarets Version 1.10 Page 6 What they could do better: • • The Registered Providers must fulfil their responsibility to carry out Regulation 26 reports, in accordance with Care Homes Regulations 2001. Social trips and access to outside areas should be facilitated for service users who have expressed a wish to be assisted to go out from the home or to sit outside. More staff should have the opportunity to be trained to NVQ level 2 and above. More staff should achieve NVQ level 2 awards in care. A significant number of staff are already undertaking NVQ level 2 awards and are expected to achieve this award in the near future. Internet and email access should be provided so the manager can access POVA clearance requests and can access websites such as Department of Health CSCI, CRB and any other relevant legislation and public information necessary for the manager AND staff to be aware of. Awareness of information that is relevant to the care industry and to care staff should be part of team meetings and staff should be facilitated and encouraged to broaden their understanding and gain a wider perspective of care. Dementia care training should be made available for all staff. Protecting Vulnerable Adult training should be made mandatory and included in the home’s induction arrangement for all new staff. The Manager and Provider should ensure that service users views are independently sought, for instance, when completing inspection comments cards a visitor or somebody who is not employed by the home could facilitate this. External painting and general tidying of dustbins and their storage should be considered to improve the external appearance of the home. The large trees could be pruned to allow more light into the front of the home. The immediate entrance hallway inside the front door should be reorganised to better accommodate the documentation and information the home wish to display for visitors. • • • • • • • Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margarets Version 1.10 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 Standards Statutory Requirements Identified During the Inspection St Margarets Version 1.10 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 standard(s) 1,3,4,5, A satisfactory admissions process ensures the home is able to meet prospective service users’ needs. EVIDENCE: These Standards have been met and have been partly achieved by an updated Statement of Purpose written by the manager. In previous inspections, Standards 2,3,4,and 5 have been regularly met. The manager stated she has refused to admit a prospective service when she assessed the home could not meet their needs. The manager is responsible for admissions and stated she ensures the home has sufficient information to make a judgement about providing care. Intermediate Care (Standard 6) is not provided by the home. St Margarets Version 1.10 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 standard(s) 7,8,10,11, Care planning is satisfactorily developed and attention to service users’ physical welfare is supported by good community facilities accessed by the home. EVIDENCE: Two Care Plans indicated there has been an improvement in the content and presentation of these files. The Care Plans were written as documents that staff considered informative and easy to use and read. Care Plans recorded a personal check by the manager to ascertain if service users are happy or have anything to report about their individual care. Eye checks, hearing and over 75 years of age checks had been arranged. Diabetic blood sugar levels and pulse rates had been recorded for one service user after the District Nurse had informed the manager of the need to follow certain procedures. Another service user attends Peterborough regional College for a ‘learning and work opportunities’ course. Community Health facilities are regularly requested by the home through GPs, District Nurses and the PMS project for older people that is operated by the Greater Peterborough Primary Care Partnership. St Margarets Version 1.10 Page 10 In the past service users and their families have been supported at a time of death. The manager stated the home would always provide care for a dying person if this were appropriate to that person’s needs and wishes. Each of the nine service users who spoke to the inspector stated they were treated with kindness and respect by all the staff. St Margarets Version 1.10 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 standard(s) 12,13,14,15, The lifestyle of service users matches their expectations. EVIDENCE: Service users stated they did not feel controlled but had freedom and choice in their lives. One service user who felt she had little choice stated this was because she could not come to terms with the decline in her health that prevented her from making the choices she would like. One service user has a job which he has managed for a number of years. The manager has encouraged this person to continue with his choice and lifestyle. All the service user who spoke to the inspector said they were pleased with the meals and the arrangements and quality of food provided. St Margarets Version 1.10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18, Service users are facilitated to make a complaint and are protected by training arrangements for preventing adult abuse. EVIDENCE: All staff bar two have received training in Adult Abuse provided by the Primary Care Partnership in accordance with the Local Authority (LA) procedures for reporting and dealing with allegations of abuse. The home has the LA guidance as policy to comply with instances or allegations of abuse. The two untrained staff are expected to attend this training in the near future. Two staff stated they would report an suspicion of abuse. Six service users stated they felt safe in the home and would make a complaint if they felt unhappy. The manager and inspector discussed that abuse training should be included in the mandatory induction training for new employees. A Recommendation has been made concerning this training arrangement under Standard 30. The home has a complaints book although no complaints had been recorded by the home. St Margarets Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24, St Margaret’s is a pleasant and clean home. EVIDENCE: St Margaret’s has been adapted from a family residence to a care home. The built environment has narrow stairs to two upper floors that are accessed by a stair lift. Passageways and rooms are small in comparison to purpose built homes. Generally the home is pleasant and facilitates communal living through the shared lounges that were used by several service users who were sitting and talking to each other. Service users’ rooms were very individualised and contained plenty of their possessions. No hazards were seen that made the home unsafe. Fire equipment is regularly checked and fire alarms are tested weekly. Recent improvements to the environment made since the last inspection have been the new carpeting to the stairs and redecoration of the stairway. It is recommended the home attend to the external painting and keep tidy the front of the home where dustbins were seen overflowing with rubbish and where large trees were reducing the amount of light to the front elevation windows. A plan for maintaining the home must be provided by the registered providers. St Margarets Version 1.10 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29,30, Service users benefit from staff who receive appropriate training. EVIDENCE: The home has a rigorous recruitment policy. Staff files read showed two references and satisfactory CRBs cleared prior to commencing employment. Staff training covers a full induction period. All staff are undertaking NVQ level 2 award training courses. One person has achieved an NVQ level 2 award in care. Other training that is arranged is appropriate to the type of care needed by service users. It is recommended that all staff acquire NVQ level 2 awards as soon as possible and that adult abuse training is included in the induction programme for new staff. St Margarets Version 1.10 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36, The manager is competent and has created a culture of openness and a homely atmosphere for service users. EVIDENCE: The manager has been employed in care work for more than 27 years and in her current post for over 5 years. Staff and service users confirmed the manager has created an open approach to managing the home. Service users said they were confident about speaking to the manager, who was observed to listen and talk to service users during the inspection. The manager facilitates service users’ meetings. The manager seeks the views of service users and has used a questionnaire to elicit response to questions about the quality of care. The views of service users that have been used by the registered provider to make a brief report is basic and should be extended to include more detail and analyses that will inform planning for future provision of care. St Margarets Version 1.10 Page 16 Staff confirmed that supervision is regular and the manager stated it is recorded and is conducted as a private and one-to-one meeting. The home does not have Internet or email access. This should be provided so the manager can access POVA clearance requests and can access websites such as Department of Health CSCI, CRB and any other relevant legislation and public information necessary for the manager AND staff to be aware of. Awareness of information that is relevant to the care industry and to care staff should be encouraged. St Margarets Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 x x STAFFING Standard No Score 27 x 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 2 N/A x 3 x x St Margarets Version 1.10 Page 18 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. Standard 33 Regulation 26 Requirement The registered providers must make suitable arrangements to comply with Regulation 26 of the Care Home Regulations 2001. This Requirement remains unmet from the last Inspection on the 12/01/2005. Timescale for action 01/08/05 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 12 19 Good Practice Recommendations Service users should be assured they have the opportunity to enjoy social trips outside of the home and the offer to sit outside of the home. The external area of the home should be improved by maintaining the external paintwork, clearing away the dustbins and pruning the trees that reduce light to the front elevation windows. The area immediately inside the main entrance should be better organised to accommodate and display the documentation and information the home wishes to display to visitors. More staff should acheive NVQ level 2 awards in care and more staff should have the opportunity to be trained to NVQ level 2 awards and above . Version 1.10 Page 19 3. 19 4. 28 St Margarets 5. 6. 7. 30 30 31 8. 33 Dementia training should be made available to all staff. Training in the Protecton of Vulnerable Adults should be included in the homes mandatory Induction training. Internet and email acces should be provided so the manager can access POVA clearnace requests and can access websites such as Departmentr of Health CSCI, CRB and any other relevant legslation and public information necessary for the manager AND staff. Awareness of information essential to the care industry should be accessed by the home. The Manager and Provider should ensure that service users views are independently sought when completing inspection comments cards. St Margarets Version 1.10 Page 20 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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 Version 1.10 Page 21 - 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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