Inspection on 18/11/05 for St Martin`s Nursing Home

This inspection was carried out on 18th November 2005.

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 Nursing Home 19/02/07

St Martin`s Nursing Home 21/03/06

St Martin`s Nursing Home 10/02/05

St Martin`s Nursing Home 21/09/04

St Martin`s Nursing Home 11/03/04

St Martin`s Nursing Home 06/01/04

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

CARE HOMES FOR OLDER PEOPLE St Martin`s Nursing Home 51 Vesey Road Sutton Coldfield Birmingham West Midlands B73 5NR Lead Inspector Elizabeth Mackle Unannounced Inspection 18th November 2005 13:15 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 Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Martin`s Nursing Home Address 51 Vesey Road Sutton Coldfield Birmingham West Midlands B73 5NR 0121 321 1789 0121 321 1789 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) Mrs Bernice Ann Underhill Mrs Lorriane Lesley Ann Holt Care Home 24 Category(ies) of Dementia - over 65 years of age (24), registration, with number Terminally ill (24) of places St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elderly, chronic sick, terminally ill over the age of 55, long and short stay, terminally ill Date of last inspection Brief Description of the Service: St. Martins Nursing Home is situated in a pleasant suburb of North Birmingham and is within close proximity of public transport and the city centre. There is a train station within 5 minutes walking distance, which provides access to intercity connections. The premises have been converted from a private residence and opened in 1992 as a care home and later extended. There is a conservatory style extension (erected 1994) situated at the rear of the building, which overlooks a large attractive garden with lawns, trees, shrubs and a fishpond. The garden is well laid out and maintained and is utilised for social events during the summer time. There is off road parking situated at the front of the building that comfortably accommodates five vehicles. The home is registered for 24 nursing beds for persons over the age of 65 years. Accommodation is provided in both single and shared rooms that are situated on both the ground floor and the first floor. It is a family owned and run organisation, care and attention to detail is evident throughout the home. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out during the afternoon of Friday 18th November 2005. This was the first of the two statutory inspections for 2005/2006. During the inspection a tour of the home was undertaken, three resident files, and the recruitment documentation for three staff were sampled, as well as other care and training records. The inspector spoke with the manager, cook, one nurse, one carer and four residents. What the service does well: What has improved since the last inspection? St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 6 A requirement was made following the last inspection in relation to care plans. It was noted from the sample of care plans reviewed that they demonstrated a more specific recording system of physical and psychological needs of the individual resident. Improvements had been made to the homes risk assessment systems. 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 Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 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 Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed at this inspection. The standards will be assessed at the next inspection. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 10 Residents receive timely and appropriate health and personal care to meet their needs. EVIDENCE: Three care records were sampled during the inspection. These were found to be generally comprehensive, and included appropriate risk assessments. There was evidence of regular review and updating of care plans. It was noted however that some risk assessment documentation was undated and unsigned by the member of staff who had completed it. A monthly dependency analysis and record of observations such as pulse, blood pressure and weight is done for each resident. Daily records evidenced that health care needs were identified by staff and followed up appropriately. There was evidence of visits and input from G.Ps, chiropodist etc. The majority of residents receive GP services from a local practice, but residents wishing to retain their own GP or register with another GP are able to do so. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 10 Service users who spoke with the inspector confirmed that they are treated with respect and courtesy. The Code of Conduct issued to all staff makes clear the standards expected of staff in relation to treating residents appropriately. A payphone is provided for use of residents and sited in a quiet, private area. The payphone can receive incoming calls, and in addition a number of residents have a telephone connected in their bedrooms. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents are offered a range of activities to met their recreational needs. A balanced and nutritious menu is provided to meet individual needs. EVIDENCE: There were no rigid rules or routines in the home, and residents were encouraged and supported to maintain family and community links. There is an activity programme and this is displayed within the home, together with a photographic record of residents enjoying a variety of activities both within and outside the home. In recent months residents had been on a visit to the Botanical gardens and on a shopping trip. Activities within the home include ball games, jigsaw, therapy tapes etc. occurring each day Monday to Friday. One member of care staff has been given responsibility for the activity programme within the home, and this appears to work well. In addition there was evidence of links to appropriate activities within the community such as residents going out to Music Hall, Christmas lunch and to a Christmas carol service. A hairdresser attends the home every two weeks. Residents spoken with confirmed that they were able to exercise choice in relation to most matters within the home. Residents are able to follow their religious observance requirements. One resident said “they’re ever so good to St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 12 me here”, another resident confirmed that he was able to go out for daily walks and would be spending the Christmas period with his family. There did not appear to be any restrictions on visitors to the home and residents confirmed that they could receive visitors without any difficulty. The residents spoken with were generally happy with the meals served. One resident said, “It’s great here, the food is good”. The menu is based on a four week “rolling programme”. The cook demonstrated a good knowledge of special diets, and any residents with food allergies. Notes are also kept on the food likes and dislikes of individual residents. Standards of hygiene in the kitchen are high, with detailed cleaning records kept and available to the inspector. It was noted that the practice is for potatoes and other vegetables to be peeled and soaked the day before use. This practice should be discontinued, as much of the nutritional value of food can be lost through soaking. Food stocks in the home appeared plentiful and varied. The dining room was pleasant, bright and well furnished. Many residents preferred to eat in their rooms, and this is facilitated. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 The complaints procedure is robust, enabling residents to feel confident that their views will be listened to. Residents are enabled to take part in the political process by voting and all new residents admitted to the home are registered on the electoral register. EVIDENCE: The home has a clear and concise written complaints procedure and a copy of this is kept within the complaints register. The register was viewed and the last complaint logged was dated January 2002. The manager confirmed that no complaints had been received after this date, and that the staff aim to resolve any issues that do arise at an early stage. Residents who spoke with the inspector confirmed that they are confident that any concerns they may have will be acted upon by staff and resolved. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, and 26 The home was maintained to a high standard; the standards of furnishings and decoration are high, and an ambience of homeliness has been achieved. EVIDENCE: The home was found to be clean, bright, comfortably furnished and free from malodours. The standard of decoration and maintenance of the building were found to be high. Attention to detail was evident throughout and this, together with imaginative use of ornaments, soft furnishings and pictures makes for a very homely and cosy environment. Residents rooms were personalized to the needs and wishes of the individual. The home has had plans drawn up that would create an additional eight single rooms (with ensuite facilities) on the ground floor. This would ensure that shared rooms would no longer be used. The overall number of places is to remain at 24. This development is in the early stages of the planning process, and the estimated date of completion is mid 2007. Each resident has access to a lockable drawer in the bedroom. The issue in relation to ensuring that each room has a lockable door has yet to be resolved, although the home has undertaken a Risk Assessment of each resident in relation to this matter. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents benefit from a stable and well qualified staff team. Recruitment processes are comprehensive and systematic, ensuring that residents are not placed at risk. EVIDENCE: The home has a stable qualified nurse team, and this ensures continuity of care to residents. For qualified nurses, records are kept of NMC registration, and re-registration with NMC checked against expiry dates. Staffing rosters were viewed, and staffing levels and skill mix across the 24 hour periods found to be appropriate. Short term absence of staff is generally covered from within the existing staff team, with the very occasional use of agency staff. Three staff files were sampled, and found to contain all relevant information, including Code of Conduct for care staff, two references, CRB checks, photographic identification etc. The home has a commendable commitment to training, with evidence of a high priority given to all statutory training. A training programme has been drawn up for the year ahead (2006) and this includes topics such as Food Hygiene, First Aid, Fire, Continence Promotion and Manual Handling. Qualified nurses within the team are enabled to fulfil their Post Registration Education and Practice requirements. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, and 38 The home benefits from a committed management team that ensures the home is well run. EVIDENCE: The home is a family business, and there is evidence of close involvement and commitment by the proprietors. One member of staff commented “the owners and nurse manager will go out of their way to help staff”. There appears to be a very open management style within the home, with both residents and staff on good terms with the management team. A “Bettal” Quality Consultancy audit was undertaken in December 2004, and the home gained QA Premium award. This exercise is due to be repeated in the near future. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 17 As part of the home’s own Quality initiative, a Service User Questionnaire has been circulated in November 2005, and feedback from this exercise was in the process of being collated. A Visitor’s Questionnaire was in the process of being circulated to provide anonymous feedback on the service provided. Regular “in house” quality audits have been undertaken during the past year looking at various aspects of activity within the home, e.g. nursing, administration, catering and housekeeping. Regular staff meetings take place, and minutes drawn up in a user friendly and informative way. Although regular staff meetings and training events take place, there is no formal system of supervision in place. There is a comprehensive Accident procedure, with evidence of appropriately completed forms and details of all accidents/incidents. It was observed that a small number of bedroom doors are wedged open, apparently at the request of the residents concerned. This practice contravenes current fire safety requirements and must be discontinued. St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 3 3 X 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 3 1 St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4) Requirement The registered person must ensure that all risk assessment documentation in relation to residents is signed and dated by the person undertaking the assessment. The practice of preparing and soaking vegetables overnight should cease. The registered person must ensure that all bedroom doors are fitted with suited locks which may be overridden in the event of an emergency. This is a long outstanding requirement from previous inspections. The registered person must develop a system of formal supervision of staff at least six times a year. This is an outstanding requirement from previous inspections. Timescale for action 01/12/05 2 OP15 16 (2) (i) 01/12/05 3 OP24 12 (4) (a) 01/03/05 4 OP36 18(2) 01/03/05 St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 20 5 OP38 23 (4) (a) (c) The registered person must ensure that the practice of wedging open of bedrooms doors ceases. 18/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Martin`s Nursing Home DS0000024895.V266734.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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