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 21st March 2006 09:30 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.V285414.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 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 st.martinsnh@btopenworld.com 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.V285414.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Elderly, chronic sick, terminally ill over the age of 55, long and short stay, terminally ill 18th November 2005 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.V285414.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector carried out the inspection over one day. Information for the report was gathered from a number of sources including: a partial tour of the home, brief discussions with three residents and three members of staff, discussions with managerial staff, a review of a range of documentation including health care records, and direct and direct observation. What the service does well: What has improved since the last inspection? What they could do better:
The home’s pre-admission assessment process needs to be further developed to ensure that all needs of prospective residents have been assessed. The use of home remedies for individual residents should be more regularly reviewed in order to protect residents.
St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 6 The home’s policy on adult protection and prevention of abuse requires to be reviewed and updated to ensure that staff respond appropriately in the event of any suspicion or allegation of abuse. 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.V285414.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 The needs assessment carried out before admission needs to be more comprehensive to ensure that all needs of the individual have been identified and can be met by the home. Opportunities are provided to prospective residents and their families to visit the home to ensure that they are happy with the service provided. EVIDENCE: The policy of the home is that each person wishing to take up a place in the home has a full needs assessment carried out by a qualified nurse in order to determine whether the needs of the individual can be met. During this process the families of prospective residents and relevant professionals such as Care Manager or Community Nurse are involved. When assessing the needs of prospective residents staff also take into account the dependency levels of existing residents to ensure that they will be able to provide all the necessary resources to meet residents’ needs. It was clear from discussion with staff that the assessment is conducted in a thorough and thoughtful way. However this was not reflected in the home’s
St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 9 pre-admission assessment documentation, which needs to be more comprehensive and to include psychological and social aspects of need. Opportunities are given to prospective residents and their families to visit the home to ensure that they are happy with the arrangements. Many prospective residents take up the offer to attend the home for an afternoon or a full day, when they can look around, enjoy lunch and meet with residents and staff. The home also offers longer trial periods of up to four weeks if required. St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The home has robust policies and procedures for dealing with medicines, to ensure that residents receive their medication as prescribed. EVIDENCE: The home keeps records of all medicines that are received, administered to individuals, and disposed of. Controlled drugs were appropriately stored in keeping with the Misuse of Drugs (Safe Custody) Regulations 1973. A controlled drugs register was maintained together with a written record that the controlled drugs are checked twice daily by nursing staff. A list of specimen signatures of nurses administering medication was maintained in the clinic room. On each medication administration record there was a photograph of the individual resident. Individual prescription records included clear guidance about the use of “as and when” medication. On a number of prescription administration it was noted that in the case of prescribed crèmes and eye drops there was a practice of ticking rather than signing the administration record. This practice is unsatisfactory, and the administration of all such crèmes and eye drops must be recorded using the signature of the administering nurse.
St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 11 The home had a policy in relation to the use of home remedies. It was noted that the use of home remedies was authorised by a General Practitioner. There is also a system of auditing the use of home remedies, and if any item is being used on a regular basis, then the General Practitioner is asked to prescribe in the usual way. A small number of records sampled indicated that the General Practitioner had not reviewed the list of home remedies for a number of years, and this needs to be addressed. St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 12 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 Residents have opportunities to take part in a good range of leisure and social activities both within the home and in the community, which add to the quality of their lives. EVIDENCE: Information was prominently displayed within the home regarding the range of activities available for residents, together with photographs of residents enjoying past activities. Available activities included Sing-along sessions, opportunities to go out for lunch, weekly film show, walks, card games, ball exercises and jigsaws. Residents were preparing for an Easter Bonnet competition to which family and friends were also invited. The home had provided, at no cost to residents, a session from a qualified aromatherapist to give residents the opportunity to enjoy hand/arm massages using selected aromatherapy oils. St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 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): 18 The home’s written policy on adult protection needs to be more comprehensive and explicit to ensure that all staff know how to respond appropriately in the event of any suspicion or allegation of abuse. EVIDENCE: The registered manager demonstrated a good understanding of how any allegation or suspicion of abuse should be managed. The home had a written policy on adult protection and the prevention of abuse which has been drawn up with reference to Birmingham City Council Multi-agency guidelines on protection of vulnerable adults, and the Department of Health “No Secrets” documents. The policy needs to be reviewed and updated and in particular needs to be more specific about the requirement to inform Social Services vulnerable adults team at a very early stage in the event of any adult protection allegation. The policy also needs to explain that staff in the home should not initiate an investigation. Training for all staff in the protection of vulnerable adults and prevention of abuse should be provided by the home. St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 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): These standards were not assessed on this occasion. EVIDENCE: St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 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): These standards were not inspected on this occasion. EVIDENCE: St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 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): 35 The home’s financial procedures help ensure that the financial interests of residents are safeguarded. EVIDENCE: Residents able to manage their own financial affairs were enabled to do so. On admission to the home a full explanation of how financial matters are handled was given to the new resident and/or the relatives. Written records of all transactions were maintained. Where the money of individual residents was managed by staff this was securely and separately stored and limited to £100 per person. On receipt of cash for an individual resident the records were signed by either two members of staff, or one member of staff and either the resident or relative as appropriate. Records of all expenditure were maintained in respect of each resident. Access to cash was limited to two senior staff in the home. St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 17 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
2CHOICE 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 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Not assessed 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 OP3 Regulation 14(1)(a) Requirement Timescale for action 01/07/06 2 OP9 3 OP9 4 OP18 5 OP18 5 OP24 The Registered Manager must ensure that Pre admission assessment process must include an assessment of psychological and social needs of the individual. 12(1)(a,b) 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. 13 (2) The Registered Manager must ensure that the medicine administration records for items such as creams and eye drops must be signed by the administering nurse. 12(1)(a) The Registered Manager must ensure that the home’s policy on adult protection and prevention of abuse is revised and updated. 18(1(c) The Registered Manager must ensure that staff receive training in protection of vulnerable adults and prevention of abuse. 12(4)(a) The registered person must ensure that all bedroom doors are fitted with suited locks,
DS0000024895.V285414.R01.S.doc 14/06/06 14/06/06 01/07/06 01/09/06 01/07/06 St Martin`s Nursing Home Version 5.1 Page 19 6 OP36 18(2) which may be overridden in the event of an emergency. This requirement (timescale 01/03/06) was not assessed for compliance on this occasion. The registered person must develop a system of formal supervision of staff at least six times a year. This requirement (timescale 01/03/06) was not assessed for compliance on this occasion. 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Martin`s Nursing Home DS0000024895.V285414.R01.S.doc Version 5.1 Page 20 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
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