Inspection on 19/02/07 for St Martin`s Nursing Home

This inspection was carried out on 19th February 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 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 21/03/06

St Martin`s Nursing Home 18/11/05

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 Lisa Evitts Unannounced Inspection 19th February 2007 09:25 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.V329572.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 Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 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 F/P 0121 321 1789 st.martinsnh@btopenworld.com www.stmartins-nursinghome.co.uk Mrs Bernice Ann Underhill 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 Lorraine 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.V329572.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elderly, chronic sick, terminally ill over the age of 55, long and short stay, terminally ill 21st March 2006 Date of last inspection Brief Description of the Service: St Martins is registered for 24 nursing beds for persons over the age of 65 years. It is a family owned and run organisation, and care and attention to detail is evident throughout the home. 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. Accommodation is provided in both single and shared rooms that are situated on both the ground floor and the first floor. There are no ensuite bedrooms available. The home has ramped access to enable wheelchair users to easily access the building and a passenger lift is available to the first floor. The home has two hoists and pressure-relieving equipment is available for residents who require this to prevent skin sores. There are showers and assisted bathing facilities, which meet the needs of the residents. The home has dining room facilities and two lounges. A “Harmony Suite” is available for residents to use and this has soft music and fibre optic lights to encourage relaxation or quiet time. Kitchen and laundry facilities are located within the home. 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. There is off road parking situated at the front of the building that comfortably accommodates five vehicles. CSCI contact details are on display and a notice is displayed to inform residents and visitors that a copy of the previous inspection reports are available from the managers of the home. The current scale of charges for the home is £475 – £595 per week. These fees are reviewed in February and are subject to change in April. Additional charges include hairdressing, aromatherapy and chiropody. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken over eight hours by one inspector who was assisted throughout by the Registered Manager and General Manager. There were 23 residents living at the home on the day of the visit and information was gathered from speaking to six residents, one visitor and three members of staff. Staff were observed performing their duties and care records, health and safety records and staff files were reviewed. A partial tour of the building was undertaken. Prior to the inspection the General Manager had completed a pre inspection questionnaire, and returned it to CSCI, and this gave some information about the home, staff and residents that was taken into consideration. No immediate requirements were made at the time of the visit to the home. What the service does well: The majority of requirements made at previous inspections had been met and this indicates a service that is run in the best interests of residents and a home that is keen to comply with regulations. Both the General and Registered Manager were receptive to suggestions made and are keen to make any changes to further improve the service. The home provides a range of activities and residents are encouraged to maintain activities outside of the home to maintain their independence. Meals are varied and nutritional and there are choices available. Special diets for medical or cultural requirements can be catered for. The home provides a clean and comfortable environment in which to live and resident’s requests are acted upon. The home maintains a core group of staff and does not use agency and this ensures continuity of care. All residents spoken with expressed a high level of satisfaction with the service provided to them and comments included: “Its a superb home” “Its very nice here” “I’m very lucky to be here” “I can get involved in quite a lot of activities” “I like the sing a longs and the exercises” “We get good food” “Good food with choices” St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 6 “I haven’t needed to complain” “I’ve got everything I need in my room” “I’ve got a beautiful room” “Staff are very good, very nice people” “Staff come quickly when I press my buzzer” “Everybody is nice” “Staff are very good, friendly and happy” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 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.V329572.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and their representatives with relevant information about the home, and this enables them to make an informed decision about the homes suitability. Pre admission assessments are undertaken to enable the home to ensure that residents can be confident that their needs can be met upon admission. EVIDENCE: The home has a comprehensive statement of purpose and service user guide and this ensures that residents are given information about the home in order for them to make an informed decision about whether they would like to live there. These documents are available in other formats such as large print to enable prospective residents or their representatives who have sensory impairments to access the information easily. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 9 Since the last inspection the pre admission assessments form has been further developed to include psychological and social needs. This ensures that the home undertakes a comprehensive assessment of the residents needs and is able to determine that the home and its staff can meet the assessed needs of the residents prior to admission. Three residents files were reviewed and all had completed pre admission assessments so that the home knew they could meet their needs. Letters of confirmation that the home can meet the assessed needs following the pre admission assessment are not sent to residents or their representatives and this is required to ensure that the resident is confident that the home can meet the assessed needs prior to admission to the home. Opportunities are given to residents to come and spend an afternoon or day at the home, and have lunch and meet with other residents and staff. This gives them the opportunity to sample life at the home and help to assist them with their decision as to whether they would like to live there. During the visit to the home, the General Manager was observed to be showing a relative of a prospective resident around the home and the Registered Manager took phone calls and invited people to come and look at the home and this shows that choice to view the home is offered. The home does not offer intermediate care. Comments from residents included: “Its a superb home” “Its very nice here” “I’m very lucky to be here” St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are met by the care staff who use care plans, which contain sufficient information to meet the residents needs. The management of medication is good and this ensures that residents receive their medication safely. EVIDENCE: Each resident has a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the resident to maintain their needs. Three residents care files were reviewed and these were found to be well organised and easy to use. There was good information on file pertaining to individual preferences and needs such as “prefers bath” “likes three pillows” “uses polygrip for top dentures” and “uses beaker with a straw”. Preference of name to be used was also recorded. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 11 There was good documentation for manual handling assessments, which included information such as “two staff and a slide sheet” and “two staff with mechanical hoist”. However the most recent admission into the home had not had a manual handling assessment completed and this did not ensure that staff knew what assistance this resident required. It was pleasing to see that the home had moved a resident from an upstairs room to a ground floor room in order to promote the safety of the resident who often tried to get out of bed unassisted. One pre admission assessment had recorded that the resident was prone to chest infections, but the care plan formulated for breathing stated “no history of breathing problems” and therefore staff may not have monitored the resident for this. All information received prior to admission should be included within the care plan. A care plan pertaining to diabetes required more information to ensure that staff knew what to look for if the resident had any complications from this condition. A resident whose condition had deteriorated had had all their care plans reviewed and re written to ensure that they provided information for staff to follow to meet the current care needs. The tissue viability nurses had seen residents who had any wounds or skin sores and there was good documentation of the wounds, which would enable staff to monitor improvements or deterioration and act accordingly. A separate chart for the recording of external visiting healthcare professionals was kept and there was evidence of General Practitioners, chiropodists, opticians and dentists visiting the residents. The majority of residents receive GP services from a local practice but residents can retain their own GP if they wish and if the GP is in agreement. Daily records contained information about how the resident had spent their day, any visitors received and any changes in condition. One member of staff commented that the care staff would like to have a handover of changes, especially if they had been on days off and this was discussed with the general manager at the time of the visit. Care staff were observed performing their duties and were assisting residents to meet their needs in a dignified manner. Residents were well presented and were wearing clothing, which was appropriate for the time of year, their age, culture and reflected personal preferences. The managers of the home provide toiletries for the residents to use at no cost to the individual resident. The management of medication was reviewed, all residents had an identity photograph and a copy of the most recent prescriptions was kept which would enable staff to check that the correct medication had been dispensed to the St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 12 home. No carry forward system is in place at the home as all medications are disposed of at the end of the cycle. Controlled drugs were appropriately recorded and balances were correct. Two trained nurses check the stock balance of controlled drugs twice a day and this would identify any errors, which may have occurred. The following shortfalls were found and were discussed with the manager at the time of the inspection; Handwritten Medication Administration Records (MAR) were not signed and these should be signed by two nurses to ensure that the correct medication is written up. Ointments were not dated when opened and this does not ensure that they are disposed of within the appropriate timescale. One resident had pain relief tablets prescribed which had been administered however there was no medication for this resident in the drug trolley. This suggests that other resident’s medication was being used and this is not acceptable. The Registered Manager was working through resident’s charts that used homely remedies and these were being reviewed by the GP as previously required. There is a pay phone located in the reception area and residents can have a phone line installed in their own rooms if they choose, which promotes independence and privacy. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in, which promotes their individuality and independence. Residents receive a wholesome and varied diet, which meets any specific dietary or cultural needs. EVIDENCE: On the day of the visit to the home residents were seen to be engaging in activities such as reading newspapers/books, watching TV, listening to the radio and completing jigsaws. Care staff were observed playing board games with the residents, which encourages interaction and stimulation for the residents. There is a daily and monthly activity programme on display on the notice board and this is in large print, which ensures that residents who have visual impairments can access the information. There were photographs on display of events, which residents had participated in and appeared to be enjoying. Activities available include craft sessions, coffee mornings; sing a longs, ball exercises and games. There are plans for a trip out to a garden centre and a summer fayre. Once a year the providers pay for residents to have a hand/arm St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 14 massage using aromatherapy oils. Some residents choose to have this more frequently and the aromatherapist comes in to the home for these residents for an additional charge. The hairdresser visits the home once a week and a church service is held once a month to enable residents to continue to follow their religious beliefs. External entertainers also come into the home to provide entertainment for the residents. Newspapers can be ordered for residents from a local shop if they request this. Comments from residents included: “I’ve got my TV and books” “I can get involved in quite a lot of activities” “I like the sing a longs and the exercises” There are no rigid rules or routines in the home and staff stated that residents go out of the home with their families to engage in activities such as going to the theatre or to the pub and one resident spoken to confirmed that his sons took him out to the pub. The home has an open visiting policy and visitors were seen throughout the day. One visitor stated that she “was always made very welcome”. Positive comments were received from residents about the meals provided and these included: “We get good food” “Good food with choices” “Food is alright” “Food is very good” The lunchtime was observed and staff were seen to assist residents in a respectful manner. Tables were attractively laid and condiments and cold drinks were available. The atmosphere was calm and relaxed and special cutlery and equipment such as plate guards (to prevent food slipping from the plate) were being used and this promotes independence. Residents are informed each day what the meal is and alternatives are catered for. The menu is based on a four week rolling programme and menus are discussed at residents meetings so that changes can be made to meet resident’s requests. It was noted that residents who require assistance with feeding were referred to on the menu as “Feeders” and this does not promote the dignity of residents, this was discussed with the manager at the time and it is recommended that more appropriate terminology is used for the resident group. Snacks are available throughout the day and these include snack bars, biscuits and fruit. Pureed food is available for residents who require a soft diet due to swallowing difficulties and these portions are served separately which enables the residents to experience the taste and texture of the foods. At the time of the inspection no resident required any special diets for medical or St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 15 cultural reasons but the manager stated that these could be catered for if required. Some residents chose to eat in their rooms and some residents preferred to eat in the smaller lounge and these requests were facilitated. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and accessible to residents and their representatives should they need to make a complaint. The home has systems in place to safeguard residents from harm. EVIDENCE: The home has a comprehensive complaints procedure in place, which is accessible to residents and their representatives should they need to make a complaint. Since the last inspection at the home, CSCI has received one complaint pertaining to the home, which was referred back to the providers to investigate, using their own complaints procedure. The home had received one complaint and there were good details of investigations undertaken and the outcome recorded. Both complaints had been resolved satisfactorily. The home had received a number of thank you letters and cards and these indicate satisfaction with the service being provided. Comments from residents included: “I don’t want to complain” “I haven’t needed to complain” St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 17 There have been no adult protection referrals made, and the home had a copy of the Multi Agency Guidelines and an adult protection policy in line with the Department of Health’s “No Secrets” to ensure that staff have guidelines to follow to respond to any allegations of abuse appropriately. Staff stated that they had received training in the protection of vulnerable adults. Staff spoken to were able to demonstrate knowledge of the procedure and this knowledge should ensure that the procedure would be implemented should the need arise. The home has a Whistle blowing policy to ensure that staff has the knowledge to protect clients/service users without fear of any reprisals. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Martins provides a clean, homely and comfortable environment to live in where residents are safe, relaxed and secure. EVIDENCE: On the day of the visit to the home, the home was found to be clean and fresh with no unpleasant odours. One visitor commented “Its always nice and clean here, nice smells and no odours” The home was bright and comfortably furnished and the standard of decoration and maintenance were found to be high. A rolling programme for decoration and plans for improvements for the home are in place. The managers are hoping to create an additional eight rooms at the home, which would mean that the shared rooms would no longer be used and the overall number of resident places would remain at 24. The home has ramped access to enable St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 19 wheelchair users to easily access the building and a passenger lift is available to the first floor. The home has two shower rooms and two bathrooms, which meet the needs of the residents at the home. It is required that assisted bath seats are deep cleaned as were found to be soiled underneath and this could pose a potential risk of cross infection and this was brought the attention of the manager at the time of the visit. Toilets had hand washing facilities and raised seats as required, which would assist residents who required this equipment. Corridors are wide and handrails are available and this enables residents to mobilise freely around the home using any aids or adaptations as required. The home has two hoists and pressure-relieving equipment is available for residents who require this to prevent skin sores. Not all wheelchairs had two footrests fitted and this is required in order to prevent any injury to resident’s limbs whilst being transferred in their chairs. The home has two lounges and two residents preferred to sit in the smaller lounge, which appeared to be quieter. A visitor commented that her friend “seemed much happier since moving into the smaller room” and the resident stated that she didn’t “like the big room because it was too noisy for her”. It is pleasing to see that the staff attend to individual requests. A large fireplace is situated in the small lounge, which promotes a homely environment for the residents to live in. The “Harmony suite” is a room dedicated for quite activities and has fibre optic lights and soft music playing, residents and their relatives can use this room as they choose. Resident’s bedrooms were personalised with items that reflected personal tastes, culture and sexuality. Shared rooms were seen and had appropriate screening in place to enable residents in shared rooms to maintain their privacy. Each resident has access to a lockable facility within their room, which promotes their privacy. Bedroom doors do not have a lock and this has been a previous requirement, which the home must address. A risk assessment in relation to each service user has been undertaken however the home must provide door locks to ensure that future residents to the home have the option of choosing to have a key to their room. Comments from residents included; “My room isn’t bad” “I’ve got everything I need in my room” “I’ve got a beautiful room” The kitchen was briefly reviewed and was found to be clean. Environmental Health Officers had visited the home in May 2006 and no requirements or recommendations were made. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 20 A hygienic and effective system for the laundry of residents’ personal clothing and bed linen was in place. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by an appropriate number of staff to ensure that their identified needs are met. Staff receive training to ensure that they have the knowledge and skills to meet the individual and collective needs of the residents. EVIDENCE: In addition to the nursing and care staff the home also employs, domestic, laundry and kitchen staff to meet all the needs of the residents. A qualified nurse is on duty at all times and four cares throughout the day and two carers throughout the night. The home maintains a core group of staff and the home had not needed to use any agency staff and this ensures that residents receive continuity of care and know who will be assisting them to meet their needs. Comments from residents included: “Staff are very good, very nice people” “Staff come quickly when I press my buzzer” “Everybody is nice” “Staff are very good, friendly and happy” The home currently has 46 of staff who have achieved a NVQ and this ensures that residents receive care from well-trained and competent staff. The home almost meet the recommended 50 of staff who hold a qualification and St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 22 are continuing to work towards this. One member of staff spoken with was very enthusiastic about commencing work towards a NVQ Level 3 in care, which will provide her with further knowledge and skills. Four staff files were reviewed and were found to contain all the required information and this ensures that residents are safeguarded from harm. The exception was that the most recent member of staff employed at the home had not had a new CRB (Criminal Records Bureau) check or POVA first check (Protection Of Vulnerable Adults) and had used a previous employers check which does not safeguard residents. It is required that staff employed at the home have a POVA first check prior to commencing employment and then work under supervision until a CRB is returned. Trained nurses Personal Identification Numbers were checked directly with the Nursing and Midwifery Council confirmation service and this ensures that the nurses are currently registered and fit to practice. Gaps in employment history had been explored and recorded. There was evidence of induction programmes in place however the manager needed to ensure that the induction is in line with the Skills for Care programme. An annual staff-training programme was in place for 2007, which had highlighted areas of training. Each member of staff had an individual training record and copies of certificates were available to support training undertaken. Staff had received training in health and safety, protection of vulnerable adults, food hygiene and dementia care. Staff have not received training in infection control and this was recommended to provide staff with the knowledge and skills to prevent cross infection occurring. Fire training was taking place on the day of the visit to the home and this will ensure that staff have the knowledge and skills to safeguard residents in the event of a fire. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This is a well-managed home run for the benefit of residents. The home routinely undertakes health and safety checks, which ensures that the residents are living in a safe environment. EVIDENCE: The home is a family business and there is evidence of commitment to the residents. The Registered Manager is a Registered Nurse and has worked at the home since 2003. The manager has a NVQ assessor’s award, which means that she can assess the staff at the home that are undertaking NVQ training. The manager is currently working towards a Registered Managers Award and this shows she is keen to continue to learn and develop new skills in order to care for residents at the home, and to lead the staff team. The manager works St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 24 as a nurse in the home and is supernumery one day a week in order to complete paperwork. The home also has a General Manager who is responsible for none nursing management such as accounts, wages, maintenance, ordering of supplies, reviewing policies and procedures and generally overseeing the home. One resident commented, “Lorraine is lovely”. Four members of staff were spoken to and they all said that they were supported well by the managers of the home. One said “There are three people to contact out of hours and I don’t feel that I can’t contact them if I needed to”. Staff and residents meetings are held regularly and minutes of these were available for review. There was evidence that suggestions or requests from residents were acted upon and examples of these are certain foods being removed from the menu and the TV being moved in the lounge to enable a better view. The home offered to purchase a larger screen TV if moving the TV didn’t solve the problem and this shows how the home work towards meeting the residents needs. A ‘Bettal’ quality assurance audit had been undertaken in January 2006 and the home was in the process of arranging for this years audit to be completed. The Directors of the home hold an annual management review. Regulation 26 visit reports are not completed and the Responsible Individual, or an appropriately delegated person, must write a monthly report following an unannounced visit to the home and these must be available for CSCI to review. One resident stated, “I wouldn’t change anything”. Three residents personal monies were reviewed and the balances were correct. Each resident had individual records for recording debits and credits. Only one signature was obtained for transactions and it was recommended that two people sign for any transactions. Receipts were available for chiropody and hairdresser visits as a full list and it was recommended that individual receipts are obtained. Access to the resident’s money is limited to certain staff in the home and this helps to safeguard resident’s monies. Some staff supervision has taken place, although is not meeting the six times a year as required and it was recommended that other senior staff are trained in how to give supervision, so that some of the task can be delegated. Supervision is required in order to identify any concerns or training requirements and helps to ensure that the home provides a skilled workforce who are competent to meet both individual and collective assessed needs of the residents. The home undertakes weekly fire alarm tests and monthly emergency lighting tests. Fire drills had been undertaken and the names of staff attending were recorded. Checks had also been completed on hoists, gas appliances, nurse call St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 25 system, electrical wiring, portable appliances, bed rails and the passenger lift to ensure that they are in safe working order for both residents and staff. Water temperature checks are recorded monthly and this ensures that residents are safeguarded from the potential to be scalded. Accident records were reviewed and these were found to be satisfactory. One residents bedroom door was propped open, at her request, however this would not safeguard the resident in the event of a fire. Any doors, which are required to be open, must be fitted with an appropriate closure, which would close in the event of a fire, and an individual risk assessment must be written. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 2 3 2 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 3 2 X 3 2 X 2 St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 27 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 OP4 Regulation 14(1)(d) Requirement Letters of confirmation that the home can meet assessed needs must be sent to prospective residents. Manual handling assessments must be completed for all residents. Pre admission information must be utilised in care plans. Diabetes care plans must provide sufficient information for staff. Two staff must sign handwritten 30/03/07 MAR charts. Ointments must be dated when opened. Staff must only use medication prescribed for individual residents. Timescale for action 02/04/07 2. OP7 12(1)(a) 15(1) 19/03/07 3. OP9 13(2) St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 28 4. OP9 5. 6. OP22 OP24 7. 8. 9. 10. OP26 OP29 OP33 OP36 11. OP38 The Registered Manager must ensure that the use and appropriateness of home remedies for individual residents are reviewed at regular intervals by the general practitioner. (Previous timescale of 14/06/06 partly met) 13(4)(a)(c Wheelchairs must have two ) footplates in place. 12(4)(a) The registered person must ensure that all bedroom doors are fitted with suited locks, which may be overridden in the event of an emergency. (Previous timescale of 01/03/06 & 01/07/06 not met) 16(2)(j) Bath seats require deep cleaning. 19 Sch 2 New employees must have a POVA first check before commencing employment. 26 Regulation 26 visits must be undertaken and a monthly report written. 18(2) The registered person must develop a system of formal supervision of staff at least six times a year. (Previous timescale of 01/03/06 & 01/07/06 not met) 23(4) Bedroom doors must have suitable closures to enable them to be left open. Risk assessments must be written for residents who request doors are to be left open. 12(1)(a, b) 30/04/07 30/03/07 29/06/07 23/03/07 30/03/07 31/03/07 29/06/07 30/04/07 St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP30 OP35 Good Practice Recommendations It is recommended that more appropriate terminology be sought for residents who require assistance with feeding for the purpose of the menus. It is recommended that staff receive training in infection control. It is recommended that individual hairdressing and chiropody receipts are obtained. St Martin`s Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Nursing Home DS0000024895.V329572.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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