CARE HOMES FOR OLDER PEOPLE
St Margarets 22 Aldermans Drive Peterborough PE3 6AR Lead Inspector
Don Traylen Unannounced Inspection 31st October 2005 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.V260084.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 DS0000015187.V260084.R01.S.doc Version 5.0 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 01733 567961 Mr Riaz Mawani Mrs Sayida Mawani Ms Kathleen Gregson Care Home 15 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (14) of places St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 1 client with LD Date of last inspection 3rd June 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 Margarets 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 DS0000015187.V260084.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the second inspection for the year 20052006. During the inspection there were 15 service users at home and the registered manager and two care staff were on duty. The inspector toured the home and spoke to several service users who were seated in the two lounges. The requirements and recommendations from the last inspection report were discussed and checked for the homes responses. Care Plans were read and the medication administration records and staff training were inspected. Observations of service user and staff interactions were made. What the service does well:
St Margarets has a friendly relaxed and homely atmosphere. Care staff and the manager are the key persons in providing care that two service users reported as “marvellous” and “would not live anywhere else”. The manager sets a clear example of person centred approach and consideration of service users needs. Her approach is ‘hands-on’ and was observed to be considerate and based on respect. The home is a smaller sized home with limited numbers of staffing able to be employed. The levels of staffing are well organised and are suitable to the needs of service users who benefit from the familiar, safe and regular care given by care assistants and the manager The manager has ensured that Care Plans have been gradually and satisfactorily improved. They are now tidy and clearly presented, well recorded and offer an informative person-centred description of the service user. The efforts and contributions made by the manager and care assistants to improve the written Care Plans is to be commended. As stated in the last inspection report, “Community Health resources are regularly accessed for service users and a strong support network with the Greater Peterborough Primary Care Partnership project for older people has been established and is a significant benefit for service users”. The home encourages service users to report their views about the home in a monthly questionnaire. St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Regulation 26 reports have started to be sent to the CSCI since the last inspection but have not been regular. Regulation 26 reports must be carried out each month and sent to the CSCI each month and a copy given to the registered manager. These reports should be considered as a quality assurance device to report on the needs and welfare of service users. The registered providers must consistently meet their responsibility to make arrangements for Regulation 26 reports to be completed on time as directed by The Care Homes Regulations 2001. Regulation 26 reports have been the subject of Requirements made in the two previous inspection reports of the 12/01/05 and the 03/06/2005. One of the two remaining Recommendations still to be fully adopted, made at the last inspection of 03/06/2005, is: “Internet and email acces should be provided so the manager can access POVA clearance requests and can access websites such as Department of
St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 7 Health, the CSCI, the 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 registered providers should meet the above Recommendation so that ability of the manager to protect service users is improved and so that the overall quality of management will improve, as would the knowledge possessed by all staff within the home. More significantly, the manager informed the inspector she has been using her own computer to compile Care Plans and other documentation and this has greatly improved the records kept by the home. However, these documents are essentially the property of the home and should be created and stored by the home with facilities owned by the home. The registered providers must seriously consider the importance of the creation and ownership and responsibility for all documentation or records used by the home. The external paintwork to the home is in need of being maintained. The front elevation of the home is looking faded and worn. A planned maintenance programme should be made available for the manager and for the CSCI to be kept informed. The strength of electric lighting used immediately inside the main entrance should be increased to provide a lighter and brighter entrance where the visitors’ book, the registration certificate and other documents on display can be more easily read. Continuing and refresher training in Dementia related care should be planned and should become mandatory training for all staff. Similarly, refresher training for preventing abuse of vulnerable persons should become an established approach to training all staff after they have received the mandatory training in abuse. The inspector acknowledges that when the registered manager has undertaken the ‘training for trainers’ in adult abuse, she should be able to provide this training to the staff at St Margarets. 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 DS0000015187.V260084.R01.S.doc Version 5.0 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 DS0000015187.V260084.R01.S.doc Version 5.0 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): 1,2,3,4,5, A satisfactory admissions process, reported in the last inspection report, continues to ensure the home is able to meet prospective service users’ needs. EVIDENCE: Service users are assessed by a Care Manager from the PCT and/or are assessed by the home should they make a private funding arrangement to live in the home. The inspector and the manager discussed the rights of all persons considered to be in need of care, to an assessment of their need conducted by the local authority. A care management assessment was read for a service user who recently moved in to the home that was a comprehensive account of her needs. The service user’s family had been involved in her admission plans. The home’s admissions process is carefully organised and is declared in the Statement of Purpose and is the responsibility of the registered manager. All prospective service users are provided with a trail period of 4-6 weeks to decide if they wish to live at the home.
St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, Care Planning is comprehensive and continues to improve. The quality of written Care Plans benefits service users through the clarity of information recorded about them, which in turn enables care staff a deeper understanding and offer appropriate care. EVIDENCE: Care Plans are very well presented and maintained. They are clear and easy to read and are a pleasure to read. They contain a depth of information that is directed by a contents page. All care Plans contain a “Policy of Plan of Care”. Two Care Plans had been reviewed by a Social Worker and had been signed by the service users. The manager and staff have been instructed and aided by District Nurses to take blood pressure, temperatures and urine tests for diabetics where considered necessary. All these have been recorded in the Care Plans. Risks of falls, moving and handling needs and the service users views on dying and wishes have been recorded. Family/relatives visits have also been recorded in two Care Plans. Health need of service users are met by the attention and support provided by the Greater Peterborough PMS project for older persons. This is a project that
St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 11 successfully supports the home (and other care home) to improve the quality of care through advice, training and clinical support services. The project regularly contacts the home and is there whenever the home wishes to consult with them. This project has enabled the home to improve their social care and has provided essential Primary Health service provision for service users. Medication Administration Record sheets were checked and found to be clearly and accurately kept and well presented. When the timing of administering medication has been altered by the suggestion of District Nurse, CPN or GP these have been recorded on the comments section included on the reverse side of the MAR sheets and are signed and dated by the manager. A “self administering” and controlled drug policy was read. No controlled drugs were stored or administered by the home at the time of the inspection. The NHS Anglia Support Partnership appointed pharmacist visits three monthly to carry out an audit. The auditing pharmacist’s letter/report dated 25/09/2005 was read and declared safe practice of the storage, handling and control of medication. A letter from Anglia Support Partnership explaining the pharmacist checking arrangements was also read. New service users details are automatically given to the pharmacist, irrespective of whether they are prescribed medication. Senior staff have been trained in the Safe Handling of Medicine and their competency is checked and recorded by the manager before they are allowed to administer any medication to any service user. St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 12 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, Service users’ lifestyles match their expectations. EVIDENCE: Service users informed the inspector they were satisfied with the attention and respect shown by the staff and the manager. Two service users stated they enjoyed the food and were always offered enough choice about food and drink. The home has reached a pragmatic approach to taking service users out. They have recognised the practical difficulties and risks when taking service users out, as the numbers of staff cannot match the attention and care necessary for the physical needs of most service users. Trips to the theatre and Christmas events and shopping have been arranged and a mobile visiting organisation called “Clothes for You” have been requested to visit the home for service users who do not wish to go out. St Margarets DS0000015187.V260084.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): 18, Service users are protected by the home procedures and practices. EVIDENCE: The home has used the Greater Peterborough guidelines to protect vulnerable adults from abuse as policy. All staff have been trained in preventing abuse and the manager has arranged to attend ‘training for trainers’ in abuse prevention. This will allow her to instruct and train care staff in the home. The inspector and manager discussed the importance of refresher training for all staff in preventing abuse. She agreed this could be provided after she has undertaken the training referred to above. St Margarets DS0000015187.V260084.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): 19,20,21,22,23,24,25,26, The home is comfortable and offers service users a safe and homely environment. EVIDENCE: A tour of the home did not reveal any unpleasant odours and was found to be generally very clean and bright. The home had clean rooms and new carpeting on the stairways and in the two lounges. The interior of the home is very pleasant and well maintained. The front entrance should be lit with a higher lux electric light. The exterior woodwork and paintwork looked worn and in need of repainting. Generally the exterior appearance of the home is uninviting and looks faded. The home should produce a planned maintenance programme for the exterior and interior that considers all aspects of repair and maintenance required of a care home. The maintenance programme should be provided for the registered manager’s information and for her to contribute to as necessary. St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, Service users benefit from trained staff and from the safe recruitment arrangements carried out for all prospective staff. EVIDENCE: Senior staff are trained in the Safe Handling of Medicine and their competency is checked and recorded and agreed by the manager before they are allowed to administer any medication to any service user. All care staff have attended adult abuse training. The manager is intending to provide additional refresher training in this topic to all staff, after she has been trained as trainer. Dementia training has been arranged for all staff. The Community Psychiatric Nurse from the Greater Peterborough PMS project for older persons services has provided this training in two separate topics. All staff are booked to attend the training for both topics. At the time of inspection three staff had achieved NVQ level 2 but all staff were undertaking this award and are expected to complete the course by December 2005. CRB and POVA first checks are conducted on all staff prior to their appointment. St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 16 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): 31,32,33,35,37, The management of the home is open and is coducted in a manner that benefits service users. EVIDENCE: The registered manager has started the Registered Managers Award. She conducts her approach in an open manner that allows staff to approach her at all times. She was observed to lead by setting an example of care based on respect and equality. Staff budgeting is not shared with the manager although the manager did not report any difficulties in staffing levels. The maintenance programme for the building should be provided for the registered manager’s information and for her to contribute to as necessary. The arrangements for staff CRB clearances and POVA checks bare conducted by the registered providers and then sent to the manager. It is recommended
St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 17 that, 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. Awareness of information essential to the care industry should be accessed by the home. Records of Care Plans, service users finances and policies for medication and abuse were read. Service users finances held by the home were checked and accounted for. St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 X St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? yes 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 OP33 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. This requirement remains unmet at the 31/10/2005. 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. Refer to Standard OP19 Good Practice Recommendations The external area of the home should be improved by maintaining the external paintwork and a planned programme of maintenance should be made available for and kept in the home. This recommendation is partly brought forward from the last inspection report of the 03/06/2005. The strength of electric lighting used immediately inside the main entrance should be increased to provide a lighter
DS0000015187.V260084.R01.S.doc Version 5.0 Page 20 2. OP20 St Margarets 3. 4. OP30 OP30 5. OP38 and brighter entrance. Continuing and refresher training in Dementia related care should be planned and should become mandatory training for all staff. Refresher training for preventing abuse of vulnerable persons should become an established approach to training all staff after they have received the mandatory training in abuse. 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. Awareness of information essential to the care industry should be accessed by the home. This recommendation is brought forward from the last inspection report of the 03/06/2005. St Margarets DS0000015187.V260084.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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