Inspection on 06/07/06 for St Martin`s House

This inspection was carried out on 6th July 2006.

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

The inspector 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 Martin`s House 09/09/08

St Martin`s House 09/10/07

St Martin`s House 12/10/05

St Martin`s House 25/04/05

St Martin`s House 03/12/04

St Martin`s House 05/07/04

St Martin`s House 11/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE St Martins House St Martins Crescent Camborne Cornwall TR14 7HJ Lead Inspector Richard Coates Key Unannounced Inspection 6th July 2006 09:15 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 Martins House DS0000008910.V292559.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 Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Martins House Address St Martins Crescent Camborne Cornwall TR14 7HJ 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) 01209 713512 01209 711444 Cornwall Care Limited Mrs Susan Margaret Crouse Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (8), Physical disability (12) St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 8 adults of old age (OP) Service users to include up to 12 adults with a physical disability (PD) Service users to include up to 20 adults aged over 65 with a dementia (DE[E]) Service users to include up to 20 adults aged over 65 with a mental illness (MD[E]) Total number of service users not to exceed a maximum of 40 Date of last inspection 12th October 2005 Brief Description of the Service: St Martins House is one of eighteen care homes owned by Cornwall Care Ltd. It is registered to accommodate forty older people in need of personal care and who are over retirement age. St Martins House provides three services: residential home, rehabilitation unit and day care provision. The residential home provides long term care to service users who are in need of personal care and are over retirement age. Admissions are planned and emergency admissions are avoided whenever possible. Health professionals make referrals to the rehabilitation unit for service users who have a physical healthcare need and require a period of rehabilitation before they return to their own homes. St Martins House provides twelve places in this unit. The length of stay is around six weeks. Day care is available at St Martins House for 1-3 service users a day. The facilities for residents are on a single floor, which is accessible to all service users. All service users rooms are single occupancy with access to lounge areas and toilet facilities. Service users can access a secure garden. St Martins House is close to the facilities of Camborne and has good transport links to the town. The fees at July 2006 were from £298.25 to £400.00 a week. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned unannounced key inspection. The purpose of the inspection was to follow up the provider’s compliance with the requirements and recommendations set in the last inspection report dated 12 October 2005, and to focus on the key national minimum standards as identified by the commission. The inspector was on the premises for two days. The methods used were discussion with the manager, staff, residents, and their relatives and visitors, inspection of records and documents, observation of the daily life of the home and inspection of the premises. The Registered Manager completed a pre-inspection questionnaire. The inspectors are grateful to the providers, staff and residents for their assistance in completing the inspection. What the service does well: Service users and their representatives stated that St Martins provides good quality care and accommodation. Service users attending day care facilities stated they enjoyed their visits to the home. Comments about staff made by residents included ‘I have a wonderful carer’, ‘very nice’ and ‘I feel secure and protected’. Residents commented that they felt that they were consulted about their care needs. Residents reported that their health needs were met to a ‘good’ standard. Records demonstrated that appropriate referrals are made to health professionals. An Occupational therapist and Physiotherapist work in the rehabilitation unit. Following their assessments and care plans, rehabilitation care staff provide each resident with an individual plan of care, which includes treatment and provides a programme of rehabilitation. A resident of the rehabilitation unit stated that she had received all the help that she needed, and she had confidence in the staff team. Residents reported that the home and local community provided a varied and stimulating programme of activities. These were observed during the inspection. Residents felt their visitors were welcomed to the home. Residents, relatives and staff felt able to approach the registered manager with any concerns and issues. The home is well maintained, tidily decorated and kept clean and hygienic. The staff team has been fairly stable and this allows staff and residents to get to know each other and promotes consistent care delivery. Residents made positive comments about the staff skills and attitudes. Staff receive regular supervision. Cornwall Care has a structured training programme and supports St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 6 and encourages staff in their training and development so that residents and their representatives can have confidence in a well trained and supervised staff team. Staff were very satisfied with the training they receive and with the support from the management team. 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. St Martins House DS0000008910.V292559.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 Martins House DS0000008910.V292559.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): 3 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The needs of service users are assessed so that they can be assured that the home can provide adequate care. EVIDENCE: Managers complete needs assessments for prospective residents and obtain assessments from the commissioning authority. Cornwall Care Ltd has a standard format for assessment and care planning which, when completed in sufficient detail, covers all the issues specified in the standard. All the residents’ records case tracked contained written needs assessments. Copies of assessments, joint care planning documents and admission information from health and adult social care assessment information were on file. However, the home’s own assessments did not consistently state where they had been recorded or identify who was present. This information would provide evidence that the prospective resident and their family were involved in the assessment. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 9 Intermediate care is provided in the rehabilitation unit. This is a separate unit, and has a multi disciplinary staff team. An occupational therapist and a physiotherapist are on site. Rehabilitation care staff follow each resident’s individual plan of care, which includes treatment and provides an intensive programme of rehabilitation. One resident’s record was case tracked. The resident made positive comments about the help and assistance that she was receiving in order to return to her home. This record evidenced that the therapists undertake detailed assessments in consultation with the resident and draw up an individual plan. This plan sets clear objectives for the rehabilitation programme. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 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 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Written care plans direct and inform staff about how to meet the residents’ health and personal care needs. The healthcare needs of residents are monitored and addressed so that their needs are met. The arrangements for the management of medicines protect service users. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. St Martin’s staff also draw up a ‘Care Profile’ - a summary of the care plan used as a working document. The care plans and care profiles directed and informed care staff on meeting the health, personal and social care needs of residents. Although there were good examples of individual care planning, some care plans, or parts of care plans, were inconsistent in providing adequate detailed directions and information for staff on meeting the diverse care needs of residents. In some assessment and care planning records the objectives and actions required were not completed. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 11 All residents case tracked had a moving and handling assessment. Falls risk assessments were included as a small part of the moving and handling assessment. Where a resident is at risk of falling, there should be a separate and detailed risk assessment to direct staff. For one resident case tracked, the review for June 2006 did not refer to two recent falls and there was no specific falls risk assessment, although there was a clear direction for staff about assistance with mobility. There appears to be no regular overview of the residents who experience falls, the time of day, where the fall occurred and the staff on duty. Daily records were completed consistently but sometimes lacked adequate detail, for example referring to a “good diet” rather than a summary of what the resident had eaten. The daily records do not reflect everything that goes on in the home. Staff keep separate daily records in respect of bathing, and, where required other specific individual care needs. Residents are all registered with local GP practices. Residents and their representatives felt that their health care needs were well-monitored and appropriate attention obtained. Staff maintain a record of medical contacts for each resident. The community nurses visit the home regularly. The Registered Manager reported that no residents currently have pressure areas; some residents are using pressure relieving equipment following assessment. The Registered Manager discussed how the staff were monitoring the healthcare needs of an individual resident with a specific condition. Medicines are stored in a locked trolley and in locked cabinets in a locked room. The room and cabinets were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. The monitored dosage system is in use. Some residents on the rehabilitation unit administer their own medication. Residents sign an agreement to the administration of medicines. Cornwall Care has a corporate policy and procedure on the handling of medicines which includes guidance on the use of homely remedies. Identified staff, who have completed training, have responsibility for the administration of medicines. The provider has audited and improved systems for the storage, recording and administration on medicines that cannot be included in the monitored dosage system, as required in the last inspection report. The administration records were complete and well maintained. Samples of stocks were checked against the medicine administration record and found to be accurate. The controlled drugs are stored in a secure controlled drugs cabinet. A sample of controlled drugs was checked against the record and found to be accurate. A record of medicines returned to the pharmacist is kept as a duplicate book. The normal practice is for the home to retain the book with one copy of the list of returned medicines, and for the second copy of the list to go with the medicines to the pharmacist. The practice here is for the whole book containing both lists to go to the pharmacist, so that the record St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 12 was unavailable for inspection. The Registered Manager should review this practice. Residents provided positive comments on the skills and caring qualities of staff. They felt that staff worked sensitively with them when assisting with personal care and respected their privacy and dignity. Examples of staff delivering appropriate and sensitive care were noted during the inspection. The Registered Manager discussed how she ensures that staff continue to treat residents with respect – for example through being out and about in the home on a daily basis, and through staff training and supervision. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. A varied range of activities takes place. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: Residents commented that there is ‘enough to do’ during the day. A variety of activities were taking place or planned. These included socialising in lounges, tai chi and head massage, crafts, art, music, bingo, outings and receiving visitors. Staff discuss activities with residents so that they can choose whether to participate. Residents told the inspector how much they enjoyed the activities. Some residents commented that they prefer to spend time in their own company and this is respected. Individual interests are recorded in service user admission information, care plans and their life story record. Residents felt that they had control over their daily lives and choices in their routines. There is a flexible visiting policy and residents determine where they meet their guests. Residents felt their visitors were welcomed to the home positively and could not think of improvements in this area. Visitors confirmed St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 14 that the home’s visiting arrangements suit them and staff make them welcome, offering, for example, a cup of tea. One gentleman regularly joins his wife for lunch at the home when visiting. The Registered Manager stated that she does not act as appointee for any resident for their benefits or manage any savings. A minority of residents manage their own finances. Other residents’ finances are managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture by agreement with the provider. Cornwall Care Ltd has introduced the ‘appetite for life’ initiative to ensure that a varied and appealing diet is provided to residents in a relaxed atmosphere. The cook reported that they have continued to review their 4-week menu and take account of residents’ wishes. There are two main choices each day at lunch, with further choices also available. The home is currently providing some diabetic diets and low fat diets. Two residents receive assistance with eating. Residents made positive comments to the inspector, and in responses to the commission survey, about the variety and quality of food provided. They can choose where to have their meals, either in their room or in the wing dining area. The inspector joined residents for lunch. This was a relaxed and sociable occasion with staff providing appropriate and sensitive support. Residents enjoyed a sherry or glass of wine and their choice of meal. Residents reported that they had a good choice of breakfast, and a range of savouries and puddings and cakes at tea. Drinks are served between meals. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 15 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 and 17 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are basic arrangements to protect service users from abuse, and these need further development. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. St Martins has received no formal complaints in the last year. The Registered Manager keeps a record of compliments. Residents reported in the postal questionnaire that they knew how to make a complaint. Residents and visitors told the inspector that they felt that they could approach the managers at the home with any concerns and these would be addressed. Cornwall Care Ltd has an adult protection policy and procedure. Cornwall Care staff in general respond appropriately to incidents and concerns about adult protection and follow the local Multi-Agency Adult Protection Guidelines. However, the company’s own policy and procedure requires some revision to comply fully with these guidelines. Staff have not received refresher training in adult protection following their induction. However, the Registered Manager reported that all staff would receive further training in adult protection this year. It was recommended to the Registered Manager that she ensures that she has a copy of the Cornwall Multi-Agency Adult Protection Guidelines. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 16 St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is well maintained and safe. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: The residents’ accommodation at St Martins House is on the ground floor and is accessible to all service users. A small area of the building is used for offices. The home is arranged in four wings. Each wing is a self-contained unit with bedrooms, dining area, lounge, toilets and bathrooms. There is a garden which is accessible to residents. Bedrooms are single occupancy. These rooms are quite small, but are pleasantly decorated and furnished. St Martins is situated in a residential area of Camborne not far from the facilities and services of the town. The car park leads to the main entrance which is suitable for wheelchair users. Cornwall Care Ltd continues to St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 18 maintain and refurbish the home’s décor and furnishings. The provider has a redecoration and maintenance programme that ensures that all parts of the home are presented and maintained to a good standard. Service users and their representatives all commented that they are satisfied with the home’s cleanliness, presentation and the quality of furnishings. All rooms inspected were clean and decorated to a good standard. The rooms were personalised and service users had the option to lock their rooms. The arms of the armchairs in the rehabilitation unit sitting room are becoming rather worn. Cornwall Care Ltd is gradually replacing the fixed wardrobes in bedrooms with freestanding furniture which allows residents more choice in the arrangement of their room. Each wing and bedrooms has an individual colour scheme as a form of signposting for residents. The provider is in the process of raising funds to develop a sensory garden. Local students have submitted a range of designs. The home was experiencing major difficulties with the hot and cold water system at the time of the inspection. However, staff and managers were managing this so that it had little effect on the daily life of the residents. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Guidance notices are posted for staff. Service users commented that the laundry service is ‘good’, with their clothes being kept clean, and did not raise any issues in this area. The bathing and toileting facilities in the home comply with the standard, providing assisted baths and a level entry shower. Toilets are suitably close to communal areas. All the bathrooms and toilets inspected were clean and hygienic. Facilities for hand washing with hand wash, paper towels and alcohol rub were situated throughout the home. Aids and adaptations were evident to assist with mobility and transfers. There were sufficient sluicing facilities in the home. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing and training arrangements ensure that the needs of residents are met. Recruitment procedures do not fully support and protect the residents. EVIDENCE: Residents commented that they felt staffing levels were sufficient, although some remarked that staff were kept busy. There are four care staff and domestic staff on duty with at least one assistant officer during the waking day in the residential area. The domestic staff support care staff by working flexibly with residents, and also become involved in activities. For the rehabilitation unit, three staff are on duty in the mornings and two in the afternoon, in addition to the professional therapist staff. At night there are 2 waking staff and an on call manager. The registered manager stated that the home has not needed to employ agency workers. Residents were satisfied with the level of staffing in the home, reporting that call bells were answered promptly, and all were positive about the skills and qualities of the staff team. Staff commented that they felt that there were sufficient staff on duty and that they worked well as a team. The registered manager stated that if the residents’ care needs became more complex she would review staffing levels and increase these where needed. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 20 A recent summary of training records showed that 29 out of 32 staff have completed their NVQ in care at level 2 or level 3. Staff in the rehabilitation unit have completed their NVQ 3 in Promoting Independence. The Cornwall Care Ltd training structure ensures that all staff are registered for their NVQ level 2. Posts are advertised through the Job Centre and local press. Cornwall Care Ltd has standard corporate recruitment procedures. Two managers interview using set questions and keep a record of the interview. The records of two recently recruited staff showed that the some required employment checks had not been properly completed. The Criminal Records Bureau disclosures and checks against the Protection of Vulnerable Adults list had been obtained a few days after staff started work, and only one reference was on file. Application forms did not detail a full employment history as specified in Schedule 2. Documentary evidence of qualifications had not been obtained. These deficits fail to safeguard residents completely. Staff records for established staff contained the required documents and information. Staff receive a statement of terms and conditions of employment. Cornwall Care Ltd provides a structured training programme for staff. Training records showed that staff were up to date with required training in moving and handling, dementia care, food hygiene and health and safety. Recently appointed staff had begun their inductions. Staff made positive comments about the training they received to do their jobs. Cornwall Care Ltd needs to review the use of the Personal Profile training record. These were not completed and up to date, but the staff member’s training history information was generally recorded on other documents. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an experienced and qualified registered manager who is determined to ensure that it meets its stated purpose and objectives, and provides the highest quality care. The health and safety of residents and staff are generally promoted and protected. EVIDENCE: Ms Sue Crouse is the Registered Manager and has experience in the care sector for thirty-five years. She has been the registered manager at St Martins House for 5 years. Ms Crouse has the HND in management of care services and dementia care certificates up to level 3, and is also a registered nurse. Ms Crouse has been on a number of training courses recently to update her training and knowledge. There are clear lines of accountability from the St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 22 Registered Manager through the assistant managers, who each have specific areas of responsibility, and supervise one of the wings and staff. Staff were extremely positive about the management support and supervision that they received. They reported that the manager was very accessible, provided support for them to do their job and encouraged them in their personal development. Staff identified the teamwork during the current problems with the water supply as a good example of how they worked well together to provide a good service to residents. Cornwall Care Ltd has corporate policies for the management of service users’ monies. Service users are encouraged to manage their own monies and hold their own accounts. Cornwall Care Ltd provides safekeeping for small amounts of money. The records show all payments in and out and a running balance. The Registered Manager reported that an inventory is now retained for all valuable items also held for safekeeping. Cornwall Care Ltd has previously sought the views of residents and their representatives, and other stakeholders through questionnaires. The Registered Manager stated that the annual quality assurance survey this year is being carried out by an external organisation. The surveys will be distributed to residents and all other stakeholders with a stamped envelope so that they can be returned directly to the external organisation for analysis. The staff records showed that all staff received at least six supervision sessions a year. This was confirmed in discussion with the manager and staff. Staff receive annual appraisals. Cornwall Care Ltd has comprehensive policies for health and safety. The preinspection questionnaire detailed required maintenance and safety records. A sample were checked against the original records and found to be accurate. Staffs have attended relevant health and safety training. Staff reported that Cornwall Care Ltd promotes safe working and manages health and safety well. The records showed weekly tests of the fire alarm system, monthly tests of the emergency lighting and regular fire training for all staff. The last engineer’s service report for the fire alarm system recommended that it needs replacing. However, it continues to work without any apparent problems. The provider should review this recommendation. The home’s fire risk assessment could not be found during the inspection. The Registered Manager has been asked to confirm to the commission whether the fire risk assessment is complete and has been approved by the fire service. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 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 X 3 X 3 3 X 3 St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 24 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 OP29 Regulation 18 Requirement The registered manager must ensure that all staff has POVA clearance before they are able to commence employment whilst their CRB is being processed. This requirement has been renotified – previous time scale of 30.11.05 not met. 2 OP7 12 The Registered Person must complete a separate individual falls risk assessment for all service users at risk of falls. The registered person must obtain two written references before employing a person to work at the care home. The registered person must obtain a full employment history, including a satisfactory written explanation for any gaps before employing a person to work at the care home. The registered person must obtain documentary evidence of relevant qualifications and training before employing a person to work at the care DS0000008910.V292559.R01.S.doc Timescale for action 07/07/06 30/09/06 3 OP29 19 and Schedule 2 19 and Schedule 2 07/07/06 4 OP29 07/07/06 5 OP29 19 and Schedule 2 07/07/06 St Martins House Version 5.1 Page 25 6 OP38 23 home. The Registered Person must confirm in writing to the commission whether the home has a written fire risk assessment which has been accepted as satisfactory by the fire brigade. 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations The adult protection policy should be expanded to include a timetable of initiating an adult protection referral and explain what procedure should be followed. St Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Martins House DS0000008910.V292559.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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