Inspection on 22/02/06 for St Martins

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 21/10/09

St Martins 24/09/09

St Martins 23/08/07

St Martins 06/06/06

St Martins 09/11/05

St Martins 09/12/04

St Martins 13/07/04

St Martins 18/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Martins Oakhill Park Liverpool Merseyside L13 4BP Lead Inspector Andrea Morris Unannounced Inspection 22nd February 2006 09:00 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 DS0000025186.V282640.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 DS0000025186.V282640.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Martins Address Oakhill Park Liverpool Merseyside L13 4BP 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) 0151 228 0983 Southern Cross Care Management Limited Jean Marjorie Redfern Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 42 Nursing Beds and 42 Personal Care Beds within an overall number of 42 beds 9th November 2005 Date of last inspection Brief Description of the Service: St Martins Care Centre is a care home that provides personal and nursing care for 42 older people. The home is situated in the Broadgreen area of Liverpool and is within easy access to bus routes, churches, shops and local amenities. The home is a purpose built single storey building. There is a car park to the front of the home; a garden is at the rear of the premises and an enclosed courtyard area for residents to sit. All bedrooms provide single accommodation and have 20 en-suites facilities. Communal space within the home consists of three lounge areas and a large dining room. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out over 5 hours. The inspector spoke to the Deputy Manager, staff and residents. A tour was made of the home. A selection of documentation was examined including resident care files, staff personnel files, certificates relating to Health and Safety as well as the fire log book. What the service does well: What has improved since the last inspection? What they could do better: Care files on the residential unit must be completed to ensure all residents have the care required documented. All care files must be reviewed appropriately, care plans needed must be evaluated and those no longer required filed away. Medication on the residential unit must be recorded accurately as detailed in the main body of the report. All complaints received into the home must be recorded and the action taken also must be documented. Only 25 of care staff hold the NVQ certificate, there must be a training plan formulated to ensure all staff are offered the NVQ training. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 6 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 DS0000025186.V282640.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 DS0000025186.V282640.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, 4, 5, 6 All residents prior to admission are visited to ensure their needs can be met. EVIDENCE: The home has amended the Statement of Purpose as directed in the last inspection. The service user guide remains adequate. All residents who enter the home are issued with a written contact, which clearly defines the terms of residency. The manager or deputy carry out a pre-admission assessment, this assists the home with maintaining a resident’s needs appropriately. Residents are able to visit the home prior to entering the home. Potential residents are encouraged to stay for a few hours for a meal if they prefer at no additional cost. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 9 There was clear evidence that the home accesses information and support from other healthcare professionals. Records are clearly maintained and to a good standard. The home does not provide intermediate care. St Martins DS0000025186.V282640.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, 11 Medication is not recorded accurately and therefore places residents at risk of harm. EVIDENCE: A selection of care files were examined. Not all care files contained written care plans. One resident on the residential unit who had entered the home a month previous did not have any care plans in place but the daily report recorded ‘care as planned’. Not all care plans on both units are reviewed on a monthly basis. This puts residents at risk, as care is not being reviewed on a regular basis. Risk assessments were found to be in most care files, however some residents have been assessed as high risk and very high risk in several areas such as falls and pressure area care. No care plans were found to support those risk assessments. Not all risk assessments were reviewed on a regular basis, not all risk assessments had been completed following admission. Medication was assessed and several areas of concern were identified on the residential unit. These included handwritten entries did not contain two St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 11 signatures per entry. Medication had been prescribed four times per day but the maximum it had been administered was twice per day thus putting residents at risk of not receiving the prescribed medication. There were several gaps in the drug sheets, this also indicates residents have not received their medication. Medication was signed for in advance and this practice must cease immediately. Medication received into the home was not recorded; on counting the medication the stock compared to the drugs administered did not correspond correctly. The medication on the nursing unit was found to be correct. Residents during the tour of the home stated they enjoyed living in the home, they stated staff treated them well. It was seen that staff maintained a good rapport with residents and their families. The homes policy on care of the dying remains adequate. St Martins DS0000025186.V282640.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 Residents are encouraged to maintain contact with family and friends, thus assisting in promoting social well being. EVIDENCE: Records of activities carried out on a twice weekly basis are maintained by the activities organiser. The home provides a variety of activities. Residents stated they enjoyed the activities provided and staff respected their decisions if they chose not to participate. The home receives visits on a weekly basis from the Roman Catholic Church and on request from the Church of England Church. The home operates an open visiting policy. Families are encouraged to visit openly. One visitor stated she was very happy with the care her relative was receiving. Staff were witnessed to offer choices to residents. Residents stated they could choose how they spent their day, and staff respected any decision they made. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 13 The menu for the home is on a four weekly rota. The menu is kept under regular review and amended to cater for the residents’ choice. An alternative to the daily choices can be provided as per request. Residents stated they enjoyed the food. The daily menu is displayed on the board in the main dining area. St Martins DS0000025186.V282640.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, 17, 18 Not all complaints are recorded. This places residents at potential risk of harm. EVIDENCE: The complaints file was examined and it was found that there have been no complaints recorded since July 2005. The home has received several verbal complaints but none documented nor have any outcomes/actions taken. Residents’ legal rights are protected through all residents being registered on the electoral role. Residents are able to maintain their right to vote, either through the postal vote system or through residents being assisted to attend the local polling station. The home displays independent advocacy information in the entrance area, any resident is able to assess their support in confidence. All residents are able to receive their post un-opened. Staff assists residents upon request. There have been no adult protection issues in the home. Some staff have received training in adult protection but some staff are waiting to have the training. A recommendation has been made for all staff to receive annual adult protection. St Martins DS0000025186.V282640.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, 20, 21, 24, 26 The re-decoration to the communal areas ensures the home remains a pleasant environment for all residents living in it. EVIDENCE: The home is well maintained and a re-decoration programme has been implemented since the last inspection. The main lounge, dining room and all corridors have been redecorated. Residents are able to access the grounds and the courtyard area via ramps. Lifts in the home are serviced regularly. The bathrooms are maintained to an adequate standard. A selection of residents’ rooms were viewed, all were found to be maintained to good standard, residents’ rooms are personalised to their preferences. Residents stated the staff respected their rooms and their property, they also St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 16 stated they could as they wish spend as much time in their rooms. Residents are also able to receive their visitors in private, and when they choose. The home during the inspection was found to be clean and hygienic. An effect cleaning programme is maintained to ensure standards are maintained. St Martins DS0000025186.V282640.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 The home is well staffed therefore providing continuity of care, this assists with safeguarding residents from harm. EVIDENCE: The staff rota was examined and found to be accurate. Little to no agency staff are used and only as a last resort. The home has recently interviewed for two night staff and are now awaiting references and the relevant checks to be made. 25 staff hold NVQ2 or above. There are no staff planned to commence on the NVQ in the near future. Staff receive training in all aspects of care. However, there are no records maintained of training received by staff. A requirement has been made for records to be made available for inspection. Training is provided through the in house training system and through external sources as required. A selection of staff personnel files were examined and found not to contain all the necessary information as detailed in schedule 2 of the National Minimum Standards. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 18 The trained staff file had no up to date PIN check for the nurse, as the current one on file had expired. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38 There is no manager in the home; a manager is required to ensure standards are maintained. EVIDENCE: There is currently no manager in post; an application must be made to the Commission for Social Care Inspection as soon as an appointment has been made. The deputy is currently managing the home; she provides leadership to the staff. The deputy manager is receiving support from another manager in the region and the Operations Manager. Satisfaction surveys are sent out periodically to relatives and residents. Copies are sent to head office and to the home. The surveys are available upon request and also kept in the entrance area of the home. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 20 Supervision is not being maintained in the home, a requirement has been made for all staff to receive supervision on an least 6 times per year. The fire log book was examined and all records maintained. A recommendation has been made for a second person to record the weekly fire alarm check in the absence of the maintenance person. The Health and Safety certificates were checked and all not found to be in date. During the tour of the home a fire wedge was found to be in place on a door where a sound activating device was also fitted, the wedge in the event of the fire would prevent the door closing. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 21 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 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 N/a N/a 3 N/a 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 N/a N/a 2 3 2 St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 15(1) Requirement Timescale for action 01/03/06 2 OP7 15(2)(b)(c) 3 OP8 13(4)(c) 4 OP9 13(2) The registered person shall after consultation prepare a written plan as to how the service users needs in respect to his health and welfare are to be met. The registered person shall keep 01/03/06 the service users plan under review and revise the plan as necessary. The registered person shall 01/03/06 ensure that unnecessary risks to health or safety of service users are identified and so far as possible eliminated. The registered person shall make 31/03/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. a) All handwritten entries must contain 2 signatures b) Medication must not be signed for in advance c) Medication must be administered as prescribed d) Medication sheets must not have gaps left in areas where a signature is DS0000025186.V282640.R01.S.doc Version 5.1 St Martins Page 23 5 OP16 22(4) 6 OP28 18(c)(i) 7 OP29 19(1)(b) 8 9 OP31 OP36 8(1) 18(2) required. e) All medication received into the home must be recorded correctly. The registered person shall within 28 days after the date on which the complaint is made, or such shorter period as may be reasonable in the circumstances, inform the person who made the complaint of the action (if any) that is to be taken. The registered person shall ensure that persons employed to work in the care home receive training appropriate to the work they perform. The registered person shall not employ a person to work in the care home unless he/she has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 in schedule 2 The registered provider shall appoint an individual to manage the care home The registered person shall ensure that persons working at the care home are appropriately supervised. 06/03/06 30/03/06 30/03/06 01/04/06 30/03/06 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 OP12 Good Practice Recommendations 1 It is strongly recommended that the hours for the activity organiser be re-assessed as activities are only being delivered over 2 afternoons. DS0000025186.V282640.R01.S.doc Version 5.1 Page 24 St Martins 2 3 4 5 OP18 OP30 OP37 OP38 It is strongly recommended that all staff including ancillary staff receive annual adult protection training. It is strongly recommended that a training record be maintained for all staff working in the care home. It is strongly recommended that another person be trained to carry out the weekly fire alarm checks to ensure compliance in the absence of the maintenance person. It is strongly recommended that all certificates relating to Health and Safety are kept up to date and a copy be retained in the care home. St Martins DS0000025186.V282640.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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