Inspection on 15/05/08 for St Marthas Care Centre

This inspection was carried out on 15th May 2008.

CSCI found this care home to be providing an Good service.

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 Marthas Care Centre 27/07/10

St Marthas Care Centre 23/03/10

St Marthas Care Centre 02/04/09

St Marthas Care Centre 08/01/09

St Marthas Care Centre 16/10/08

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Marthas 55-63 Victoria Road Stechford Birmingham West Midlands B33 8AL Lead Inspector Lisa Evitts Key Unannounced Inspection 15th May 2008 09:45 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 Marthas DS0000071082.V363425.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 Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marthas Address 55-63 Victoria Road Stechford Birmingham West Midlands B33 8AL 0121 789 7926 0121 783 5547 stmarthas@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd 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) Post Vacant Care Home 38 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (38) St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 38 Mental Disorder, excluding learning disability or dementia, Code MD maximum number of places 1 The maximum number of service users who can be accommodated is: 38 New Service 2. Date of last inspection Brief Description of the Service: St Martha’s residential care home, provides care and accommodation for older people in two buildings, Ash House and Cedar House and there is a separate registered nursing home on the same site. The home has been established for a number of years however was acquired by Southern Cross Healthcare in November 2007. Ash House provides accommodation for twenty-five people over three levels. There are three double bedrooms and the remainder are single occupancy. There are two lounges and a dining area with access to patio doors, which lead out onto the garden. The home has assisted bathrooms and a shower room to meet the needs of the residents. Cedar House provides accommodation for thirteen people over three levels. There are two double bedrooms and the remainder are single occupancy. Some of the rooms on the upper level require residents to be able to manage some steps. A passenger lift is available to the first floor and there is a stair lift to the second floor. Cedar house has a lounge and a separate dining area. The home has two hoists and a stand aid, which can assist residents with decreased mobility. Pressure relieving equipment is sought via the district nurses for residents who require this to prevent skin sores. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 5 St Martha’s and the separate nursing home share a spacious, well maintained patio/garden area, comprising of a small water feature and gazebos. St Martha’s is about a fifteen-minute walk from the Bordesley Green Road, where there is a main bus route into Birmingham City Centre and a railway station is nearby. Limited off road parking is available. Laundry facilities are situated in the nursing home, as is the main kitchen. There are a number of notice boards throughout the home, which provide various articles and leaflets that may be of interest. Copies of the previous inspection reports are also on display for anyone who may wish to read them. The current scale of charges for the home is £343 - £473. Additional charges include the hairdresser, chiropodist, optician, dentist, physiotherapy, aromatherapy, reflexology and pre planned hospital visits. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. St Martha’s is an established residential home, which was acquired by Southern Cross Healthcare in November 2007. Two inspectors undertook this fieldwork visit to the home, over eight hours and a half hours and the acting manager assisted us throughout. The home did not know that we were visiting on that day. There were 33 people living at the home on the day of the visit. Information was gathered from speaking to and observing people who lived at the home. Three people were “case tracked” and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Two other files were partly looked at. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. Random questionnaires were sent out in order to gain peoples views about the service. Eight people who live at the home, eight staff and one healthcare professional returned questionnaires. These contained positive comments about the service provided and are included within this report. Three people who live at the home and three staff were spoken to. A thematic inspection was also completed during the day, which involved us asking a set of questions. A thematic inspection is a focused inspection that looks in detail at a specific theme. This inspection looked at safeguarding, which means that we looked at how well people are protected from abuse or neglect in adult social care. We will publish these findings in a national separate report. Prior to the inspection the operations manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements and plans for further improvements, which was taken into consideration. Regulation 37 reports about accidents and incidents in the home were reviewed in the planning of this visit. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 7 No immediate requirements were made at the time of this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: People are provided with current information about the service offered to enable them to make an informed decision about whether they would like to live at the home. They can visit the home to see if they would like to live there. People who use the service have access to a range of Health and Social care professionals and this ensures that any healthcare needs are met. Care plans provide detailed information for staff to follow to ensure that people’s personal and individual choices are maintained. The management of medication ensures that people receive their medication as prescribed. There is an open visiting policy and people are made welcome in the home. People are offered a choice of meals, which meet any dietary, cultural needs or personal preferences. People are provided with a homely and comfortable environment in which to live where privacy is maintained. Staff receive training to ensure that they have the knowledge and skills to perform competently within their roles and to meet the needs of the people who live in the home. People told us: “Its home from home” “I love it here, I wouldn’t go anywhere else” “The carers help me to put lipstick on and earrings” “The girls open post for me and read it to me, I like that” “Food is wholesome, what you would make at home” “Its always edible” “We have no complaints at all” “I would definitely tell the staff if I was unhappy but I haven’t had to” “Our bedroom is lovely, it’s nice” “They treat you well and look after you” “Staff very easy to talk to” “Staff come when you press the button” “They act promptly upon concerns and monitor residents well” St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 9 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 Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have sufficient information about the home to enable them to make an informed decision about whether they would like to live there. Pre admission assessments do not ensure that people know their needs can be met prior to moving in. EVIDENCE: The organisation has produced a comprehensive service user guide and statement of purpose. The statement of purpose and service users guide was displayed in the reception area of the home, which ensures that the information is available to people if they choose to read it. The service users guide is also in each person’s bedroom. The documents can be made available in large print and audiocassette so that people with visual impairments can access the information. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 11 Prior to moving into the home staff complete pre admission assessments. We looked at the assessments of the two people who had most recently moved into the home. These did not contain enough details about their needs or about how staff would need to assist them. The manager was able to tell us a lot of information, which had not been recorded as part of the assessment, and this should be recorded so that people know that their needs can be met when moving into the home. People who would like to come and live at the home and their relatives are able to visit the home, and are encouraged to stay for a day. This means that people have the opportunity to sample what it would be like to live at the home, helping them to make an informed decision. The home does not offer intermediate care facilities. People told us: “Its home from home” “I love it here, I wouldn’t go anywhere else” St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provide good information for staff to assist people to meet their individual needs and preferences. People’s health and personal care needs are well met. The management of medication ensures that people receive their medication as prescribed. EVIDENCE: Each person had a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the person to maintain their needs. We looked at three peoples care files in detail and two files were partly reviewed. There was some good information about individuals’ personal care needs and preferences so that people should receive care in a manner they need and like. Care plans described people’s skills so that they remain as independent as possible, for example, “can wash and dress top half of body but needs assistance with bottom half”. One person’s plan stated that they liked to have a foot spa but there was no evidence in the documentation that the person had St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 13 received this. The manager said that this was part of the bathing/showering routine, however it should be documented that it has taken place so that there is evidence that staff are following care plans. Care plans were evaluated monthly and were updated as changes occurred. This included any information received by the home following hospital appointments. Care plans for specific problems such as diabetes or infections gave details on what staff should look for. Triggers of difficult to manage behaviour were detailed, and included how to reduce this behaviour, which means that staff have guidance to follow and use a consistent approach to meeting peoples needs. Care plans were written for short term needs but one had been removed from the file as soon as the treatment had been completed and it is recommended that plans are not archived too soon as they provide an audit trail. Risk assessments are undertaken for falls, nutrition and skin soreness so that staff can act upon any changes in conditions as required. Moving and handling assessments were detailed with type of equipment to be used and included details of how to assist people from the floor if they fall. Records showed that people have regular appointments with healthcare professionals such as the district nurse and GP. The outcome of this contact had been documented so that staff had accurate information about people’s state of health. One healthcare professional told us “The carers communicate well with the residents and other professionals. They act promptly upon concerns and monitor residents well”. The management of medication was robust and all audits undertaken were correct. Medication is signed for upon receipt into the home and copies of prescriptions are kept so that staff can check they receive the correct drugs. Controlled medications were securely stored and fridge temperatures are recorded to ensure that medication is appropriately stored. People appeared to be well supported by staff to choose clothing appropriate for the time of year, which reflected individual cultural, gender and personal preferences. One person told us “the carers help me to put lipstick on and earrings”. People can have their own telephones in their rooms at an additional cost or a payphone is available for people to use. One person told us that she received a lot of letters from her family and said “the girls open post for me and read it to me, I like that”. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to choose the activities that they participate in which promotes their individuality and independence. People are offered a choice of meals to meet their dietary, cultural needs or preferences and are supported by staff during meal times. EVIDENCE: The home has a dedicated activities coordinator who works at the home full time, and shares her time across the three houses on site. The home has a four weekly activity programme which consists of a variety of games, sing a longs, art, cinema, reminiscence and gardening. The programme rota is displayed on notice boards within the home and is in each person’s bedroom. A monthly newsletter is produced which remembers people’s birthdays, provides a quiz and some poetry. The home has external entertainers such as progressive mobility every two weeks. A garden party is planned in June and people are being consulted about day trips out of the home. The hairdresser visits each week and a church service is held once a month for those people who wish to participate. There is no demand for any other type of worship amongst the current group pf people who live at the home. People are St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 15 able to have their newspapers and magazines delivered so that can continue to read articles, which interest them. In the surveys returned a number of people living at the home indicated that there were “sometimes” activities available that they could join in and it is recommended that staff ensure that all people’s leisure needs are being met. During the day people were observed reading magazines, playing a large connect 4 game and one person was playing an organ. There was a good atmosphere in the home. People can go out with their families as they choose and this encourages their independence and assists them to maintain links with the community. The home has an open visiting policy and this enables people to see their visitors as they choose, enhancing their quality of life. People told us: “We watch TV, we are pleased with it” “I’ve just had a TV for my room” “I have visitors everyday” The home has a three-week cyclical menu in place however this is due to be changed to the Southern Cross menu and the introduction of the NUTMEG system, which is a nutritional analysis system. This software package helps to plan a balanced meal. There is a choice of two hot meals at lunchtime and a choice of salad, sandwiches or hot snack for the evening meal. Snacks are available and include, yoghurts, fruits, biscuits, crisps and fruit juice. People were observed to have their meals in the dining room, which was nicely presented. People told us: “Food is wholesome, what you would make at home” “Its always edible” “Food is ok” The development of the menu will be reviewed at our next visit to the home to ensure that it meets the needs of the people who live there. St Marthas DS0000071082.V363425.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. 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 service. The complaints procedure is comprehensive and is accessible to people should they need to make a complaint. The home has policies, procedures and staff training, which should safeguard residents from harm. EVIDENCE: The complaints procedure is displayed in the home and is included in the statement of purpose and service user guide so that people know how to make a complaint if they need to. The second page of the complaints procedure, which was displayed in the reception area, was missing and did not give people our contact details should they need to contact us. This was brought to the attention of the manager on the day of the visit. The home had received one informal verbal complaint regarding standards of cleanliness in the home. This had been documented and included details of actions taken to resolve the complaint. We have not received any complaints since the new owners took over the home in November 2007. In the reception area there is a compliments book, which has a number of thank you cards and letters, which suggests satisfaction with the service provided. People told us: St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 17 “We have no complaints at all” “I would definitely tell the staff if I was unhappy but I haven’t had to” Surveys returned to us from people living at the home indicated that people were aware how to make a complaint if they needed to. The home had an adult protection policy in place and had the local multi agency guidelines to follow; this ensures that staff have guidelines to follow in the event of an allegation being made. The home also has a protocol for staff to follow should they find any unexplained bruising or skin tears. As part of the ‘thematic’ inspection on safeguarding (protecting people from harm) we spoke to three members of staff. Staff were unfamiliar with the term ‘Safeguarding’ and thought it related to health and safety, but when the terminology was changed to ‘adult protection’ they were able to demonstrate a good knowledge of how to safeguard people from harm, should an allegation be made. All of the staff have had recent training in adult protection and this should ensure that they have the knowledge and skills to act appropriately to protect people in the event of an allegation being made. The home has a whistle blowing policy, which should ensure that staff act appropriately in the event of an allegation, without fear of reprisal. There have been no allegations of an adult protection nature made at the home. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with a homely, clean and comfortable environment in which to live where their privacy is maintained. EVIDENCE: Access to the home is via a doorbell and this ensures that people know who is entering the building to ensure that people are safe. A partial tour of the home was completed to review areas which were relevant to the people we case tracked. The Annual Quality Assurance Assessment (AQAA) told us that a rolling programme for redecoration of bedrooms and replacement of carpet and furnishings had been developed to meet the shortfalls in the environment. The dining room in Cedar house was in the process of being redecorated during our visit and some bedrooms had been redecorated. This will enhance the St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 19 environment for people to live in. The home is none smoking and people who want to smoke would have to go outside of the home to do this. The atmosphere in the home was friendly, calm and relaxed. People living at the home were engaging in conversation with each other and it was clear that they felt this was their home. There were no unpleasant odours in the home, which indicates that regular cleaning routines are in place. There were a variety of chairs for people to sit in and there was pressurerelieving equipment in use to prevent people from developing sore skin. The home has hoists to assist people with mobility problems. The homes have various bathing and showering facilities so that people have a choice and can be assisted by staff if required, to meet their personal needs. One bathroom floor was noted to have torn flooring where a bath seat had been replaced and this was brought to the attention of the manager as it posed a potential trip hazard. Bedrooms seen were very personalised and reflected individual tastes, gender and cultural preferences. People are encouraged to bring in their own possessions in order to have familiar items around them to make their rooms as homely as possible. One bedroom floor was noted to have torn flooring and this was brought to the attention of the manager as it posed a potential trip hazard. The manager confirmed that it would be taped down until it could be replaced to minimise the risk of injury due to tripping over. Due to the number of changes planned, outcomes for people living at the home will be further assessed at our next visit to the home. People told us: “Our bedroom is lovely, it’s nice” “I’ve just had a TV for my room” St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by staff who receive training to ensure that they have the knowledge to meet individual needs. The recruitment procedure does not make sure that people are safeguarded from harm. EVIDENCE: The home has three care staff in Ash and two staff in Cedar throughout the day. At night there are three staff in Ash and one in Cedar, however the third person in Ash goes to work in Cedar from midnight until 6am. The home currently has two vacancies for nighttime care staff and is actively recruiting staff into these posts. In addition to care staff the home also have domestic, laundry, administration and maintenance staff to ensure that all the needs of the people living in the home are met. The home maintains a core group of staff, and rarely uses any agency staff, which means that people know who will be assisting them to meet their needs. 55 of care staff have a NVQ level 2 in care and this should ensure that staff have the knowledge and skills to care for the residents individually and collectively. Some of the remaining staff are about to start this training. People told us: “They treat you well and look after you” “Staff very easy to talk to” St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 21 “Staff come when you press the button” “I find the staff good here they are doing their job” We looked at four staff files and these were found to contain the majority of information required to safeguard people from harm. The exception was one file, which did not have satisfactory references as there was no reference from the previous employer and one reference received was from someone who was not listed in the employment history. This information is required to ensure the safety of people living in the home and was brought to the attention of the manager. There was evidence that staff receive induction training and this should mean that staff have been introduced into the home and have the knowledge to perform well within their roles. There were copies of training certificates available on staff files and the training matrix was reviewed. Staff have completed in house training in fire, food hygiene, moving and handling, COSHH (Control Of Substances Hazardous to Health), health and safety, abuse, infection control, nutrition, pressure area care, customer care, challenging behaviour and dementia awareness. Some staff are enrolled at a local college to complete training in the safe handling of medicines. This should enhance staff’s knowledge and skills to enable them to meet people’s needs individually and collectively. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people who live there. EVIDENCE: The home has been through a number of changes recently, including the change of ownership and the loss of the previous home manager. Staff have however continued to run the home in the best interests of the people living there. The acting manager was the deputy manager of the home and has a good knowledge of the people living at the home and their families. She has a National Vocational Qualification (NVQ) level 3 in care and has an assessor’s St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 23 certificate. The manager told us that other home managers and senior managers within the organisation had supported her. There have been staff meetings held at the home and minutes from these meetings were available. A residents and relatives meeting had been held but there were no minutes from this meeting and it is recommended that these are available to people who live in the home. These meetings give people the opportunity to discuss any concerns or ideas about the home in an open atmosphere. Senior managers visit the home and complete Regulation 26 visit reports which report on the quality of service being offered at the home. The organisation has a number of audits in place to monitor the service provided and had recently sent out customer satisfaction questionnaires in relation to laundry, catering and activities. The results of these questionnaires were displayed along with an action plan to rectify any shortfalls. Prior to the inspection the Operations Manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements and plans for further improvements, which was taken into consideration. Individual records are maintained for people where the home holds personal monies. The balance of money was correct against the cash held in the safe and this should ensure that people’s money is held safely. Health and safety and maintenance checks had been undertaken in the home to ensure that the equipment was in safe and full working order. Maintenance checks were made of the fire system to establish that it was in full working order. Staff had recently received fire drills so that they had the knowledge to act appropriately in the event of a fire occurring. One entry stated that the staff were still confused about what to do when the fire alarm was activated. A further drill was performed but the names of staff attending and the date of this were not recorded. It is recommended that further drills are undertaken so that staff know what to do to safeguard people living in the home in the event of a fire. St Marthas DS0000071082.V363425.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 3 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 X X 2 St Marthas DS0000071082.V363425.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. Standard Regulation Requirement Timescale for action 1. OP19 13 (4)(C) Flooring must be made safe to 30/06/08 ensure that the risk of people tripping is reduced. 2. OP29 19 Sch 2 Satisfactory references must be 19/06/08 obtained prior to staff commencing work at the home to ensure the safety of people living in the home. 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. 4. 5. Refer to Standard OP3 OP7 OP12 OP32 OP38 Good Practice Recommendations Pre admission assessments should contain sufficient details so that people know that individual needs can be met. Short-term care plans should not be removed from care files too soon as they help staff to monitor peoples conditions and response to treatments. Staff should ensure that all people have access to activities they prefer to ensure people are stimulated. Minutes from meetings should be available to people living in the home so they are involved with decision making. Training should be given so that staff know how to safeguard people in the event of a fire occurring. St Marthas DS0000071082.V363425.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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