Inspection on 09/10/07 for St Martin`s House

This inspection was carried out on 9th October 2007.

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 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 Martin`s House 09/09/08

St Martin`s House 06/07/06

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 Martin`s House St Martins Crescent Camborne Cornwall TR14 7HJ Lead Inspector Mike Dennis Unannounced Inspection 9th October 2007 10:00 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 Martin`s House DS0000008910.V347802.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 Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martin`s 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 stmartins.home@cornwallcare.org Cornwall Care Limited Mrs Susan Margaret Crouse Care Home 40 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (22), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (22), Old age, not falling within any other category (18), Physical disability (3), Physical disability over 65 years of age (18) St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Service users to include up to 18 adults of old age (OP). Service users to include up to 18 adults with a physical disability (PD[E]). Service users to include up to 22 adults aged over 65 with a dementia (DE[E]). Service users to include up to 22 adults aged over 65 with a mental illness (MD[E]). Total number of service users not to exceed a maximum of 40. Up to 3 Service Users over the age of 59 and below the age of 65 in the categories Dementia (DE), Mental Disorder (MD) and Physical Disability (PD). The total number of Service Users not to exceed 40 6th July 2006 Date of last inspection 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 nursing who are over retirement age. A limited number of people attend day care at the home. This care home with nursing provides long term care to service users who are in need of personal care and/or nursing care and are over retirement age. Admissions are planned and emergency admissions are avoided whenever possible. 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 October 2007 were from £400 to £680 a week. Additional fees are occasionally charged in special circumstances. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 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 6th.July 2006, and to focus on the key national minimum standards as identified by the commission. We were on the premises for two days. During the second day of the inspection two inspectors were present The methods used were discussion with the deputy 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 the Annual Quality Assurance Assessment form. We are grateful to the providers, staff and residents for their assistance in completing the inspection. What the service does well: Staff told us that they receive a variety of good training, to include regular fire training, mental health training, induction training, medication training, venepuncture and Protection of Vulnerable Adults training. They also said that they felt the staff team was working much better as a cohesive team. Residents told us that the majority of staff were excellent. They have the opportunity to engage with therapists on a one to one basis and also take part in various other activities and interests. The food provided is varied and to a good standard. Individual needs and choices are provided for. Employment policies and procedures are followed to ensure that vigorous checks are made as to the individuals suitability to work in a care environment. The Head Office team are committed to making St. Martins a success with the introduction of nursing care at this service. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Since the introduction of nursing care to this home there have been a number of staff changes. Firstly the requirement to employ nursing staff and the inability of some existing staff to easily embrace change has resulted in the need to employ agency staff. The staff team are now more settled and agency staff have been reduced to minimal levels. It now remains to bond the team into a cohesive workforce. Some residents and their relatives are unsure as to future developments within the home. Ongoing communication with these people will help to give reasons and hopefully allay fears. Care planning and the delivery of care is generally good but there have been occasions when it could have been better. The streamlining of documentation is underway and it will be important to ensure that records are maintained to the highest standard. Now that St. Martins is registered as a Care Home with Nursing, the qualified nurses should take responsibility for all medication practices in the home. The cleanliness of the home is variable with some areas being most hygienic whilst others are less so. This area of work needs constant monitoring. Training and supervision of staff is ongoing and is promoted by Cornwall Care. There are some examples where this can be improved upon. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 7 The implementation of a quality audit may provide further information which could aid improvement. 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 Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents receive the information they require in order to make an informed choice about residing at St. Martins and their needs are assessed so that they can be assured that the home can provide the care required. EVIDENCE: Information is given to prospective residents by of a Statement of Purpose, Service users Guide and brochure. The senior staff present were unable to access the most recent Statement of Purpose outlining the nursing provision provided. It is important that up to date information is given to prospective residents. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 10 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. The four residents’ records case tracked in detail contained written needs assessments. Commissioning information from health and adult social care was also on file as were contracts and statements of terms and conditions. Assessments stated who was present, providing evidence that the prospective resident and their family were involved in the assessment. Intermediate care is no longer provided at this home. St. Martins has successfully applied to become registered as a Care Home with. Nursing. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 11 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. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health, personal and social care needs are set out in individual plans of care but not all have been regularly reviewed. Medication procedures are in general appropriately followed but some improvements by way of attention to detail will improve processes. Residents report satisfaction with their health care. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. This system is going through a period of change to the Standex System. We noted that some care plan records were kept on the new system whilst others are still recorded on the old system waiting to be transferred. St Martin’s staff also draw up a ‘Care Profile’ - a summary of the care plan used as a working document. The care St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 12 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. Information relating to residents was not always seen to be held in one place which made case tracking more difficult. It is recommended that all information gathered in respect of each resident is kept on a master file. The Standex file can then be used as the working document. All residents case tracked had a moving and handling assessment. Falls risk assessments are now compiled allowing staff to conduct overviews on these incidents. This information can feed into a review of the care plan. We noted that not all care plans had been reviewed at the required monthly intervals. There was a clear direction for staff about assistance with mobility. Daily records were completed consistently and generally to a good standard but sometimes lacked adequate detail. The daily records need to reflect everything that goes on in the home. More information concerning the social and emotional aspects of a residents life would be welcome. 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. The majority of 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 Deputy Manager reported that four residents currently have pressure areas and stated that in two cases these occurred whilst the person was in hospital. She reported that all four were progressing well. Some residents are using pressure relieving equipment following assessment. The Deputy 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 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. Given that this home now has nursing status it would be more appropriate for all medicines to be administered by nursing staff. The provider has audited St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 13 and improved systems for the storage, recording and administration on medicines that cannot be included in the monitored dosage system. The administration records were complete and well maintained, although some gaps were noted in past administration records. 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. Unused/unwanted medicines are now disposed correctly via the appropriate disposal bins. Records should be kept of all medication disposed. Where hand written entries are made on the medication administration records, they should be accompanied by two signatures. The temperature of the storage room, not to exceed 25C, needs to be monitored. The medical fridge needs defrosting. Creams/lactulose etc. are all contained in individually named pots. It was also positive to note that alcohol gel was available on the medication trolleys and being used. A G.P. visited the home during the inspection to undertake a medication review. 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. St Martin`s House DS0000008910.V347802.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. . Residents are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: The majority of 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 us 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. Some residents told us that there was insufficient attention and stimulation. We observed a high level of staff input to the nursing areas but St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 15 less so in the residential side of the home. Comments from some visitors claimed that since nursing care was introduced to the home, staff seem to have less time for social interaction. 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 that the home’s visiting arrangements suit them and that generally staff make them welcome, offering, for example, a cup of tea. The Deputy Manager stated that the manager 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. Some residents receive assistance with eating. Residents made positive comments to us concerning the food provided to them. Staff should ensure that help with feeding is carried out promptly to prevent the meal going cold. Residents choose where to have their meals, either in their room or in the wing dining area. 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 Martin`s House DS0000008910.V347802.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. St Martins has recently received a formal complaint which is currently being investigated. The Registered Manager keeps a record of compliments. Residents told us that they knew how to make a complaint. Residents and visitors told the inspector that they would 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. The company’s own policy and procedures have been revised and updated since the last inspection. The majority of staff have received training in adult protection. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well presented but some areas require attention to ensure that residents live in a well-maintained, clean and hygienic environment. 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 St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 18 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 maintain and refurbish the home’s décor and furnishings. The provider has a redecoration and maintenance programme aimed at ensuring that all parts of the home are presented and maintained to a good standard. Some areas of the home are in need of improvement. Specifically, certain areas require new carpets, a ceiling repair is needed (previous water leak) and a floor service hatch in a bathroom requires attention. The deputy manager informed us that these items had been recognised and would be remedied in the very near future. In general the cleanliness of the home was to acceptable standards. We did observe some areas in residents rooms where this was not the case. In talking to staff, some felt a night cleaner would be an asset. Residents stated that they are satisfied with the presentation and the quality of furnishings. The majority of rooms inspected were clean and decorated to a good standard. The rooms were personalised and residents had the option to lock their rooms. 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. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Guidance notices are posted for staff. Residents commented that the laundry service is ‘good’, with their clothes being kept clean, and did not raise any issues in this area. One relative is less happy saying that clothes have gone missing. 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. 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 St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 19 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. We were told that odour control in certain areas had been a problem. There was a slight odour during our tour of the building but within acceptable standards. Replacement of floor coverings has helped to eradicate this problem. St Martin`s House DS0000008910.V347802.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures support and protect the service users. Staff are trained and competent to meet the needs of residents. The staffing levels are generally satisfactory. EVIDENCE: Residents commented that they felt staffing levels were sufficient, although some remarked that staff were kept busy and that priority seemed to be given to the nursing residents. There has been an increase in staffing levels since the introduction of nursing care. Overall it is considered that staffing levels are satisfactory but care must be taken to ensure they are evenly dispersed throughout the home. We were told that there has been some staff difficulties in the recent past requiring the employment of agency workers. We were also told that this is not generally the case now and it would appear that a regular staff team is now available. Residents told us that they were generally satisfied with the level of staffing in the home, but would like to see more of the management team out on the floor. No complaints came forward 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. We St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 21 observed less staff available in the general care section of the home which links to the previous statement of ensuring that staff cover is appropriately distributed throughout the home. A recent summary of training records showed that the majority of staff have achieved NVQ awards Qualified nursing staff are also employed and all are checked to have current registration through their governing body the NMC. The training records for nursing staff clearly identified their training needs. These records do not indicate if and when these needs have been realised. We can only assume therefore that the training has not been implemented. If this is the case training courses as identified should be accessed immediately and up to date records maintained. All staff are recruited following set down company procedures. We tracked this process in respect of six staff and found that all had been competently managed to include application forms, references, proof of identity and CRE and POVA checks. 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 St Martin`s House DS0000008910.V347802.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, 34, 35, 36, 37, 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an experienced and qualified registered manager. The health and safety of residents and staff are generally promoted and protected as are their financial interests. There are areas where improvement can be achieved. EVIDENCE: St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 23 Ms Sam Jacobs is the Registered Manager. She is supported by a deputy manager and three care coordinators and a link nurse, all of whom make up the senior staff team. Ms. Jacobs is a Registered Mental Nurse. 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 Deputy Manager stated that the last annual quality assurance survey was carried out by an external organisation. The next quality assurance survey is now due. The staff records showed that staff receive supervision. There was not enough recorded evidence to determine that all staff were receiving this supervision at the required time intervals, ie. Six times per year. Cornwall Care Ltd has comprehensive policies for health and safety. A sample were checked against the original records and found to be accurate. Staff 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. St Martin`s House DS0000008910.V347802.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 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 3 3 2 2 3 St Martin`s House DS0000008910.V347802.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. 1 Standard OP7 Regulation 15 Requirement Care plans are to be reviewed at monthly intervals and where practical any changes discussed with the individual concerned Records must be kept of the disposal of all medicines to include those placed in disposal bins. Staff are to receive supervision at least 6 times per year. Evidence must be recorded to confirm compliance Timescale for action 31/01/08 2 OP9 17 30/11/07 3 OP36 18 31/01/08 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 OP1 Good Practice Recommendations Ensure that all residents and prospective residents are given or have access to the latest version of the Statement of Purpose. Care plans clearly state what action/goals are to be DS0000008910.V347802.R01.S.doc Version 5.2 Page 26 2. OP7 St Martin`s House achieved. It is important to document the results of such action plans on review of the care plans. 3 4 5 6 OP9 OP9 OP27 OP33 Qualified nursing staff should administer medication throughout the home. Hand written entries to the Medicines Administration Record should be witnessed by two signatures Ensure the distribution of staff throughout the home is commensurate with residents needs It is recommended that a Quality Audit review is undertaken in the near future. St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI St Martin`s House DS0000008910.V347802.R01.S.doc Version 5.2 Page 28 - 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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