Inspection on 06/06/06 for St. Margarets

This inspection was carried out on 6th June 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 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 13/12/05

St. Margarets 07/06/05

St. Margarets 19/01/05

St. Margarets 05/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Margarets St Margarets Care Home 99 Carlisle Road Eastbourne East Sussex BN20 7TD Lead Inspector Merle Blakeley Unannounced Inspection 6th June 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 DS0000046888.V291481.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Margarets Address St Margarets Care Home 99 Carlisle Road Eastbourne East Sussex BN20 7TD 01323 639211 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) office@saint-margarets.co.uk Total Support Solutions Ltd Miss Teresa Howell Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-two (22). Service users must be older people aged sixty-five (65) and over on admission. 13th December 2005 Date of last inspection Brief Description of the Service: St Margaret’s is registered to provide residential care to twenty-two older people. At the time of the inspection, sixteen people were accommodated. The home is a large, detached, three-storey, Grade 2 listed building situated in the Meads area of Eastbourne. The home is located within walking distance of local amenities and the main seaside town is a few minutes drive away. Resident accommodation consists of sixteen single rooms and three shared rooms. Many of the bedrooms have en suite facilities. Communal areas comprise of a lounge, reception and landing seating areas and a large dining room. The external grounds offer an attractive and well-maintained garden to the rear of the property. Parking facilities are available at the front of the home. The home has a series of chair lifts, which enable residents to access all three floors of the home. The current fees are from £350.00 to £700.00 per week and there are additional charges for hairdressing, chiropody and newspapers. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of eight hours on 6th June 2006. As well as this site visit, information was also gained from a pre-inspection questionnaire, feedback survey forms from residents and visitors, informal talks with eight residents, two visitors and four staff members plus the manager. The site visit consisted of a tour of the premises, looking at the needs of four particular residents, document reading, lunch with the residents and observing staff and resident interactions throughout the day. What the service does well: What has improved since the last inspection? The home has worked hard to complete all but one of the requirements that were made during the last inspection. The service users guide has been updated to include additional staff information. Care plans and risk assessments are being regularly reviewed and updated. The home is carrying out all the required recruitment procedures when appointing staff. Resident’s finances are safeguarded. All windows that are above ground level are now restricted. The home has discontinued the practice of propping open fire doors. Fire doors have been fitted with magnetic door guards and these allow doors to close automatically if the fire alarm should be activated. A fire risk assessment and a new vent for the boiler cupboard have also been completed. Since the last inspection two bedrooms have been redecorated and the stair lift chairs have been replaced. The manager has recently successfully completed the Registered Managers Award. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has produced an up-to-date service users guide and statement of purpose. Prospective residents are assessed prior to moving into the home. EVIDENCE: A previous requirement was made at the last inspection for the home to update the information in the service users guide and statement of purpose. This was viewed on the day and now includes information about the staff team and their qualifications. The home carries out an assessment on all prospective residents to ensure that the home can meet their needs. These assessments are either carried out in the person’s home or they are invited to come into the care home. The home will normally receive a social work history and care plan about the resident and following this the manager will carry out her own assessment. Trial visits to the home are encouraged and a two-week trail period is offered. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home maintains informative and up-to-date care plans and reviews. Resident’s healthcare needs are being met. Medication procedures need to be reviewed, as some discrepancies were found. During this inspection residents were seen to be treated with dignity and respect by staff. EVIDENCE: During the last inspection the home was required to regularly review and update residents care plans to ensure that their changing needs were being met. The home has improved the review and recording procedures regarding care plans. Several care plans were viewed and they were found to be informative and up-to-date. Residents risk assessments were also required to be reviewed and updated and the home has now met this requirement. Most of the residents are now involved in the review of their care plans; relatives and friends are also invited to attend these reviews. Information from care plans revealed that residents have access to a number of healthcare professionals such as local doctors, district nurses, chiropodist, optician and dentists. An incontinence nurse is due to come into the home St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 10 soon to provide training for staff. Staff will accompany a resident to an appointment if that is their wish. At the moment one resident is administering her own medication and a risk assessment has been carried out. A review for this risk assessment was last carried out in March 2006. Medication records were checked and two discrepancies were found. Staff must always sign for any medication that is given and PRN medication must always be dated. The manager will be required to discuss and review medication procedures with staff. There are currently five named staff members who administer medications and all have attended medication training. During the day staff were observed interacting with residents and it was evident that staff are treating residents with dignity and respect. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents stated that the home meets their expectations. Visitors are made welcome in the home. Residents are able to exercise control and choice in their everyday lives. The home is providing residents with a well-balanced and nutritious diet. EVIDENCE: During the day several residents were spoken to and they were asked if they were happy with the level of activities that the home offered. Most of them stated that they were happy with the activities that were organised by staff and the majority said how much they enjoyed the light exercise classes, boules, film evenings and quizzes. A few residents go out independently and visit family and friends. Visitors are welcome in the home and they are able to join their relative for lunch if they wish. Three visitors were spoken to on the day and all stated that they were always made welcome in the home. Most residents stated that that they could exercise control and choice in their daily lives. Mealtimes are flexible and residents can come and go as they wish and get up at whatever time they like. They can choose their level of St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 12 participation in the home and be able to discuss any issues or concerns during residents meetings. Menus were viewed and residents were asked about the meals that were provided by the home. The vast majority of residents said they were very happy with the meals and felt they were being offered a well-balanced and nutritious diet. The kitchen was viewed and the chef was spoken to during the day. The kitchen is very well organised and all the meals are freshly cooked each day using local produce. The menus contain a good balance of meals, which include various options and on the day there were four choices of desserts. Alternative diets and food preferences are catered for. It was evident that resident’s ideas and wishes regarding certain types of meals had been taken into account and had been included on the menu. The inspector was able to enjoy a very pleasant lunch with the residents. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. The home has a complaints policy and procedure and there is a policy and procedure for the protection of vulnerable adults. EVIDENCE: The home has a complaints policy and procedure, which is available to all residents and visitors. A copy is currently on display in the lobby entrance. The manager stated that residents are reminded of the complaints procedure at each residents meeting. There have been no complaints made to the home. The home has a policy and procedure regarding the protection of vulnerable adults, which was written in 2002. It will be recommended that the home review this policy to ensure that the information it contains is still relevant. The vast majority of staff have attended training in adult protection. There are two more staff members who are booked to attend this training soon. There are no adult protection concerns within the home. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 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, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is attractive, spacious and comfortable. Outstanding health & safety matters within the home have been addressed. The home needs to be assessed by a qualified occupational therapist. The home is very clean and tidy. EVIDENCE: St Margaret’s is a Grade 2 listed building located in a quiet residential area of Eastbourne. The bedrooms and communal areas of the home are all decorated to a very good standard. Some of the original windows are in need of replacement and the home has organised for work to be carried out on four of the bedroom windows this month. A new boiler is also due to be installed within the next two months. In February this year all the stair lift chairs were replaced. The loft hatch requires repair. All windows in the home are now restricted and magnetic door guards have been installed on all fire doors. These were previous outstanding requirements that have now been addressed. Residents who were spoken to on the day spoke very positively about the St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 15 wonderful environment they live in. The property also has a well-appointed large rear garden, which includes a vegetable patch. Feedback from residents and a visitor did state that it would be nice if the home had a ramp to the front door to allow for easy independent access of wheelchairs. This covers the area of adaptations and the home needs to be assessed by a qualified occupational therapist to ensure that all the necessary adaptations, aids and equipment are available to residents should they need them. During this visit a tour of the premises was carried out and the home was found to be very clean and tidy. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current staff team appear to work well together and provide a good level of care. Staff are progressing well with their NVQ qualifications. The home is carrying out suitable recruitment procedures. Staff are receiving a good level of training. EVIDENCE: On the day of this visit there were sixteen residents living at St Margaret’s. Rotas show that there are normally three care staff, a domestic, the chef and the manager on duty during the morning. In the afternoon there are two care staff. The home feels that it is currently meeting the needs of all the residents. Staff on duty were spoken to throughout the day and all stated that they enjoyed working at the home and felt supported by the manager. Comments from residents and visitors also stated that they felt the staff team were caring, helpful and friendly. One comment card did mention that at times they felt the home did not have enough staff on duty. The staff team are progressing well with their NVQ training and to date four staff have completed this training with a further three staff half way through their training. Another two staff members will commence NVQ training later this year. One staff member has also become an NVQ Assessor. Several recruitment files were viewed and they now all contain the required information as set out in Schedule 2 of The National Minimum Standards. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 17 Staff have attended a number of training sessions this year, which have included fire training, protection of vulnerable adults, manual handling, dementia study day and infection control. Some staff are also due to attend training in first aid and basic food hygiene. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is competent and qualified to run the home. Regulation 26 visits need to be carried out on a monthly basis. No health & safety issues were identified during this visit. EVIDENCE: The manager is a qualified nurse and has recently successfully completed the Registered Managers Award. The home is managed effectively and both residents and staff stated that the manager was supportive and approachable. Residents also said that they felt the manager acted upon any issues or concerns that were raised with her. The home has a quality assurance programme. Residents meetings are held regularly and recorded. The home also meets with families to discuss care plans. Satisfaction surveys are carried on with residents and relatives. It is St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 19 recommended that the home also include sending satisfaction surveys out to visiting professionals, such as doctors, district nurses etc. During this visit none of the proprietors were available. It will be required that the proprietors carry out a Regulation 26 unannounced monitoring visit each month to ensure that the level of quality is being maintained throughout the home. During the last inspection there were a number of health and safety issues, which needed to be addressed. A fire safety officer inspected the home on 10th January 2006 and made a number of requirements. The home has completed all of the fire safety items that required attention. All doors that were being propped open have now been installed with magnetic door guards. The boiler cupboard now has the required vent and the home has updated and reviewed the fire risk assessment. All windows are suitably restricted. No other health & safety issues were identified during this visit. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 X X X 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 X 2 X X X X 3 St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 21 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 Timescale for action 01/08/06 2. 3. OP9 OP22 13(2) 23(2)(n) That the Registered Provider conducts monthly Regulation 26 unannounced monitoring visits to the home. (Previous requirement from 1/3/06) That all medications are correctly 01/07/06 entered and signed for by staff. That the home is assessed by a 01/09/06 qualified occupational therapist. 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 OP26 OP18 OP33 Good Practice Recommendations That the home considers the need for future sluicing facilities. That the homes adult protection policy and procedure is reviewed. That the homes quality assurance programme includes obtaining feedback from visiting professionals. St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margarets DS0000046888.V291481.R01.S.doc Version 5.1 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. 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