Inspection on 02/06/05 for St Martins

This inspection was carried out on 2nd June 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 Martins 26/06/08

St Martins 24/04/07

St Martins 02/05/06

St Martins 25/10/05

St Martins 07/12/04

St Martins 06/07/04

St Martins 29/03/04

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE St Martins 59 Imperial Avenue Westcliff on Sea Essex SS0 8NQ Lead Inspector Valerie Buckle Unannounced 2 /3rd June 2005 nd 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 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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Martins Address 59 Imperial Avenue Westcliff on Sea Essex SS0 8NQ 01702 475891 01702 471631 banning@missionofhelp.fsbusiness.co.uk The Mission of Help Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Susan Joan Field CRH Care Home 29 Category(ies) of DE(E) Dementia - over 65 (28) registration, with number OP Old age (28) of places PD Physical disability (1) St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Care for residents with a physical disability is restricted to one client whose details are known to the Commission. 2 Number of service users for whom personal care to be provided shall not exceed 28 (total number to not exceed 28). 3 Personal care to be provided to no more than 28 older people over 65 years of age. (total number to not exceed 28). 4 Personal care to be provided to no more than 28 service users with dementia over the age of 65 years of age. (total not to exceed 28). Date of last inspection 7th December 2004 Brief Description of the Service: St. Martins is a large older style detached home situated in a pleasant residential area in Westcliff on Sea. The home is close to public transport and local shops. The home provides accommodation and care for up to twenty eight older people, all or some of whom may suffer from dementia. Additionally the home has a condition of registration, which allows it to offer care to one named person, who is under sixty five and has a physical disability. Accommodation is on three floors with a shaft lift provided. Accommodation comprises of 23 single and three double bedrooms, 6 of which have en-suite facilities, there are two separate lounges, a large dining room, a room for visitors and a conservatory lounge which leads out to a large well maintained attractive garden. There is limited parking to the front of the property. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Not all standards will have been inspected at this inspection. Records, practices, policies and procedures have only been sampled. At future inspections other issues may come to light. This inspection was unannounced and took place over four hours. Seven residents and two family members spoke about life at the home, four members of staff were spoken to and the manager assisted in the process of the inspection. Twelve of the sixteen requirements from the last inspection were met, four are being processed. The five good practice recommendations were met. What the service does well: What has improved since the last inspection? All staff have completed training in the Protection of Vulnerable Adults, and Dementia. Some of the residents bedrooms have been redecorated and recarpeted. Bathrooms and corridors on the first floor have been decorated with stencilling on the walls. Comments from residents were that they were pleased with these changes in the décor. A new care planning system is in place; new forms are used for assessment, care plans and risk assessments and they cover all areas of resident needs. A system is in place which monitors the quality of care of the home. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 New residents and their families are given adequate information about the home, so that they can make informed choices about where to live. EVIDENCE: The home has developed a service user guide and Statement of Purpose, these include all the required information. Residents who are able are encouraged to read the service users guide, copies of which are kept on each residents file and displayed on the notice board. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 Residents health and personal care needs are appropriately met. Improvements have been made in the care planning process and risk assessments. Appropriate systems are in place for the safe handling, recording and storage of medication. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 10 EVIDENCE: The initial assessment procedure is detailed and covers all areas of resident needs and wishes. Relevant professionals, the new resident, and their family are involved in this process and their plan of care. Health and personal care is detailed in residents care plan. A medication policy and procedure were seen, residents medication records were appropriately recorded and stored safely in the treatment room. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 Daily activities are varied and depend on individual needs and choices of residents. Visitors are made very welcome and residents are happy with the choices of routines offered to them. The menu is well balanced and interesting, and offers choice and variety. EVIDENCE: A variety of activities are provided. An activities board is displayed, residents choose their daily activities and make suggestions at residents meetings. Through discussions with staff, family members and residents, it was clear that residents are involved in making decisions and choices about their daily routines. Visitors to the home said they were made very welcome, and the atmosphere is homely and relaxed. They also expressed that the staff are very friendly and welcoming. Residents are asked daily which foods they would like to eat, records and kept of choice of meals. Residents when asked were very complimentary about the food choices they are offered. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 12 During the inspection the inspector spoke to a number of residents living at the home, comments from residents were: “I am very settled living here, I have lived in this home for four years and seen many changes and the home is at its best so far”. “The staff are very kind and caring, my family are made very welcome”. “I am very comfortable living here”. “The food is good, there is always an alternative, everywhere is clean and the gardens are beautiful. A sample of records seen were appropriately documented and kept safe. Systems were in place to protect the safety of residents. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 All staff are aware of the issues relating to the protection of Vulnerable Adults. Effective systems are in place for protecting residents. Regular training is provided in areas relevant to meet staff and residents needs. EVIDENCE: All staff have completed training on the protection of Vulnerable Adults. It was evident that staff training is a high priority in the home, training records showed that regular training is planned for all staff, areas of training include mandatory training, handling aggression, dementia, Parkinson’s disease, continence, staff supervision and the safe use of medication. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20,21,22,26 St Martins provides care and accommodation to residents in a homely comfortable environment. The large garden is well maintained and easily accessible to the residents. Residents rooms were clean and attractively presented, the home is clean, safe and hygienic. EVIDENCE: The home is a large older style detached house. There are a variety of comfortable communal areas including a visitors room and a large conservatory to the rear of the property, which leads out to an attractive garden. On inspection most of the residents rooms seem to be clean and personalised to individual taste, with the exception of one room although clean had a stained carpet and there was an odorous smell. The inspector was told that this carpet is to be replaced within the next two weeks. Residents spoken to said they were happy with their rooms and found the atmosphere in the St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 15 home very relaxing. Residents were seen relaxing and talking to each other in the conservatory area, comments were its “lovely here, warm and cosy and the view into the garden is beautiful”. There are sufficient bathing facilities and toilets available in the home. A recent plan has been finalised which includes re-designing and upgrading of the bathrooms and sluice rooms. The manager said building works should start shortly. The temperature in the treatment room was very warm. The air conditioning system which is in place in the treatment room does not effectively regulate the temperature. Consideration should be given to using an alternative room for treatments and the storage of medication or installing a new system of air conditioning. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29,30 The vetting and recruitment of staff is good and protects the residents, arrangements are in place for staff induction and supervision. Training courses for all staff take place regularly. EVIDENCE: At the time of the inspection there were adequate staff on duty to meet the needs of the residents, the rotas showed that there is a sufficient skills mix of staff on duty at all times. Two staff files were studies and these evidenced that a thorough recruitment process was being followed, which protects the residents. There is an intensive staff training programme in place, staff training records were examined, it was evident that training of staff is a high priority in the home, each week staff members attend courses in relevant areas which are specific to the needs of residents. The majority of the staff group are involved in NVQ training, two members of staff have completed NVQ2 and the manager is completing NVQ4. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36,37 The manager is supported by her deputy in improving the service which is provided. The staff demonstrated a competent, caring approach to the residents. Appropriate procedures are in place to safeguard residents finances. EVIDENCE: Staff members spoken to said that they found the manager very approachable and willing to consider new ideas, comments from staff were, “we receive regular supervision and lots of training is available, we work as a team and support each other”. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 18 Most of the residents finances are managed by their families, some are managed by a solicitor. A system of quality monitoring is in place and the home has completed a self-assessment audit and achieved level 2 in P.Q.A.S.S.O. A yearly evaluation of the home which includes the views of residents, their families, staff and trustees of the home takes place and the information is collected and formulated into a report and a copy is sent to the C.S.C.I. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 19 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 x 2 x 3 3 4 3 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 3 2 x 3 x x 2 Score Standard No 7 8 9 10 11 Score 3 3 3 x x Standard No 27 28 29 30 x 3 3 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No 16 17 18 Score x x 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 4 34 3 35 3 36 3 37 x 38 3 St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? 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 OP26 Regulation 13(4)a Timescale for action The registered person must Carried ensure that all parts of the home forward to which service users access are next free from hazards to their safety, inspection this includes the unlocked sluice room. Requirement 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 Good Practice Recommendations Standard OP26 16(2) The registered person must ensure that odour is managed C&K and new carpets provided where necessary. St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend, SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Martins I56 S15469 St Martins V226315 270505 Stage 4.doc Version 1.30 Page 22 - 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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