Inspection on 02/05/06 for St Martins

This inspection was carried out on 2nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Martins 26/06/08

St Martins 24/04/07

St Martins 25/10/05

St Martins 02/06/05

St Martins 07/12/04

St Martins 06/07/04

St Martins 29/03/04

Similar services:

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 HOMES FOR OLDER PEOPLE St Martins 59 Imperial Avenue Westcliff On Sea Essex SS0 8NQ Lead Inspector Pauline Marshall Key Unannounced Inspection 11:00 2nd May 2006 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 Martins DS0000015469.V290815.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 Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Martins Address 59 Imperial Avenue Westcliff On Sea Essex SS0 8NQ 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) 01702 475891 01702 471631 sue@stmartinscare.org The Mission of Help Ms Susan Joan Field Care Home 29 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability (1) St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Care for residents with a physical disability is restricted to one client whose details are known to the Commission. Number of service users for whom personal care to be provided shall not exceed 28 (total number to not exceed 28). Personal care to be provided to no more than 28 older people over 65 years of age. (total number to not exceed 28). Personal care to be provided to no more than 28 service users wih dementia over the age of 65 years of age. (total not to exceed 28). 25th October 2005 Date of last inspection 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 twentyeight 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. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £335.00 to £520.00 and there are additional charges for hairdressing, chiropodist, taxi’s, newspapers, outside visits and holidays. Accommodation is on three floors with a shaft lift provided. Accommodation comprises of 22 single and 2 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 DS0000015469.V290815.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for four and a half hours. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff, and a visiting relative. As part of this inspection surveys were sent to six residents, two relatives and two General Practitioners to obtain their views on the service the home provides. Three residents surveys were returned and all were positive in their comments, saying how good the home was and that staff were nice and responded well to any requests. Two other survey forms were returned, one from a relative and one from a local GP, both were positive in their response. Twenty-four of the thirty-eight standards were inspected. What the service does well: What has improved since the last inspection? The daily records have improved since the last inspection and are now written in a more detailed way giving a better account of the activities undertaken by the residents. There have been improvements made in the area of dementia care and staff has undertaken further training in dementia. The home has themed areas to enable those with dementia to recognise the use of them. The home continues with its plan of redecoration and has completed many bedrooms and communal areas. The home now has an additional assisted bath. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 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 DS0000015469.V290815.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 Martins DS0000015469.V290815.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): 1, 2, 3, 6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home carries out a thorough pre-admission assessment of needs and provides prospective residents with sufficient information to enable them to make an informed choice. EVIDENCE: The homes Statement of Purpose and Service User Guide is regularly reviewed and provides clear up to date information on the services offered. Prospective residents are able to visit the home prior to admission and can do so as often as they feel is necessary for them to make a decision. A thorough assessment of needs is carried out prior to admission and the care plan is developed from this document, the home confirms that they can meet the needs of the individual in writing before admission takes place. A visiting relative, who commented on the high quality of care the home provides, confirmed this process. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 9 A contract containing the terms and conditions of residency is given to each resident upon admission. St Martins does not provide intermediate care. St Martins DS0000015469.V290815.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): 7, 8, 9, 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The homes care plans contain the information required to meet the residents’ needs and are being continually improved to provide clearer guidance to staff. Health care needs are fully met and there is a clear medication policy that is followed by all staff. The guidelines stored in with the MARS records needs to be reviewed. Residents are treated with respect and their dignity and privacy is upheld. EVIDENCE: Care plans examined evidenced that the care provided is regularly reviewed and that any changes in residents’ health, personal or social needs are met. The format for the care files is in the process of being improved. The daily recording has improved since the last inspection and provides clear information on each resident’s daily activities. The home has a clear medication policy. Guidelines that were kept with the MARS (Medicine Administration Records) were dated 2/7/04 these need to be reviewed. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 11 When administering the medication on the day of the inspection, the senior carer left the trolley open and unattended with medication on the top of the it whilst administering to residents. The medication should never be left unattended, as this could be a hazard for residents. The medication records inspected were clearly and accurately completed and changes to medication were noted on the reverse of the MARS sheet. Appropriate coding was used for any medications not administered. Residents are called by their preferred name and this is documented in their care files. Residents spoken with confirmed that they felt treated with respect by staff and that they could see their visitors in private. St Martins DS0000015469.V290815.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, 13, 14, 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents experience a lifestyle that matches their needs, they are encouraged to maintain contact with family and friends and have as much choice and control over their lives as possible. Residents receive a wholesome appealing balanced diet in spacious pleasing surroundings. EVIDENCE: During the pre-admission assessment, a residents’ social history is gathered, this includes their likes and dislikes and any particular interests and hobbies they enjoy. The home ensures that the information they receive is as detailed as possible and will include the input from friends and relatives where the residents are unable to provide full information themselves. Residents, and a relative spoken with confirmed that contact with family and friends is encouraged by the home and that visitors are always made welcome and there is adequate provision for them to meet in private if they wished to. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 13 Regular residents meetings are held and notes of these are available. Residents are encouraged to participate in the meetings and make their views known. Events are planned throughout the year and they include singers, musicians, pantomime, mobile museum, murder mystery, magician and a cockney afternoon with pie & mash & liquor and the pearly king. On the day of the inspection there was a visit from a singer dressed in RAF uniform and he sang wartime songs. Residents spoken with said how they enjoyed this entertainment and they were observed singing along with him. Menus showed a good choice of lunches and teas, the food offered on the menus is nutritious and varied. On the day of the inspection the food offered and chosen by residents was as described on the menu and looked appealing. The dining area is large and the tables are spaced neatly apart, residents who need assistance at mealtimes sat at one table. A staff member was observed speaking to a resident slowly and clearly and repeated herself when the resident wanted clarification of what she had said. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 14 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, 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Complaints are acted upon swiftly and all issues are taken seriously by the home. Staff are well trained and residents are protected from abuse. EVIDENCE: The home has a good clear complaints policy that was reviewed in December 2005. There have been four complaints in the last twelve months, all of these have been dealt with by the home in a satisfactory manner and have been appropriately recorded. The Adult Protection Policy was reviewed in October 2005 and staff spoken with confirmed that they had been trained in Adult Protection procedures and showed a good awareness of any actions they would need to take. All staff have received training on the protection of vulnerable Adults. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 15 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, 21, 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents live in a safe well-maintained environment with sufficient communal facilities that are clean, pleasant and hygienic. EVIDENCE: The home has a variety of comfortable seating areas that include two large lounges, a large conservatory overlooking an attractive garden and a visitor’s room. All the bedrooms inspected were well furnished and several have been re-decorated since the last inspection. All the repairs identified at the last fire inspectors visit have been carried out. The home is providing themed areas to assist those with dementia to identify the uses of the rooms. The home is in a good state of repair and has sufficient communal facilities for the people it serves. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 16 The home has a planned schedule of building works and improvement plan that was updated on 13th April 2006. The plan shows the estimated costs and how the home intends to fund them. A new affinity bath has been fitted and will be in use as soon as the new flooring has been fitted. On the day of the inspection a bin full of soiled incontinence pads was found in the bedroom of a resident that had been admitted to hospital twelve days before. All clinical waste must be disposed of in line with the homes infection control procedures. The remainder of the home was found to be clean and hygienic. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 17 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, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staff are well trained, competent and supplied in sufficient quantities to meet residents needs. The homes recruitment practice does not meet all the requirements to support and protect the residents. EVIDENCE: The staff rota reflected the staff on duty on the day of the inspection and it identified the various staff roles. The agreed staffing level of one senior and four care staff were on duty throughout the day. In addition to this, there was sufficient domestic and catering staff on duty. Records showed that staff undertakes a wide range of training and that three care staff have completed their NVQ and ten staff are nearing completion. The deputy manager is undertaking NVQ 3 and the manager NVQ 4. Staff spoken with said that the training the home offers is excellent. Five staff files were inspected and two contained the relevant references required under schedule 2 of the Care Standards Act. Two references must be obtained for all staff working within the home. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 18 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, 33, 35, 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and run in the best interests of the residents and their financial interests are safeguarded. The health, safety and welfare of the residents is promoted and protected. EVIDENCE: The manager has managed the home since April 2004 and is a Registered General Nurse and is nearing completion of the Registered Managers Award. The Trustees of the home support both the manager and her deputy in the improvements being made and encourage continual development of the service. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 19 The home regularly consults with residents, relatives, visitors and staff and carries out an evaluation of their responses. The home keeps its own check on the inspections standards met at each inspection and compares the information with previous years. The home is half way through level 3 of the P.Q.A.S.S.O (a recognised quality assurance system) and intends to complete this year. The home will provide the CSCI with a copy of its report on the most recent survey by the end of May 2006. The home does not hold residents monies, the residents and their families deal with their finances. The manager is aware of her duties under Health and Safety and all staff have received training. The safety certificates for equipment and services were inspected and are all up to date. Regular fire drills take place and all fire checks are carried out and recorded. St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 20 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 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 X 3 X 3 X X 3 St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Timescale for action The registered person shall make 30/06/06 arrangements for the handling and safe administration of medicines in the care home. This refers to the updating of guidelines and medication that was left unattended whilst staff administered. The registered person shall make 30/06/06 suitable arrangements to prevent the spread of infection. This refers to the bin of soiled incontinence products that was left in a resident’s room. The registered person shall not employ a person to work at the care home until they have obtained all the documents specified in Schedule 2. This refers to the need to obtain two references for all employees. Requirement 2. OP26 13 (3) 3. OP29 19 (b) (i) 30/06/06 St Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 22 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 Martins DS0000015469.V290815.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex 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 DS0000015469.V290815.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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