Inspection on 23/08/07 for St Martins

This inspection was carried out on 23rd August 2007.

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

The inspector 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 06/06/06

St Martins 22/02/06

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 Mrs Claire Lee Key Unannounced Inspection 08.50 23 and 24th August 2007 th 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.V343465.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 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 Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 42 Nursing Beds and 42 Personal Care Beds within an overall number of 42 beds 6th June 2006 Date of last inspection Brief Description of the Service: St Martins is a care home that provides personal and nursing care for forty two 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. St Martins is a purpose built single storey building. There is a car park to the front of the home and residents have the use of an enclosed garden at the rear and also an inner courtyard with seating. All bedrooms provide single accommodation and have twenty en-suites facilities. Communal space within the home consists of three lounges and a large dining room. One of the lounges is a designated smoking area. Residents are provided with equipment and aids to assist their mobility and an alarm system with a call bell is operational throughout the building. The home is attractively decorated and provides comfortable accommodation. The fee rate ranges from £405.50 to £654.00 a week. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over a two day period for a duration of approximately thirteen hours. Forty two residents were accommodated at this time. A partial tour of the premises took place and a number of care, staff and health and safety records were viewed. Discussion took place with ten residents, eight staff, the manager, operations manager and regional financial administrator. During the inspection five residents were case tracked (their care files were examined and their views of the service were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Interviews also took place with three relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection in June 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents and relatives prior to the inspection and some were also left for health care professionals and relatives to complete at the time of the visit. Comments included in the report are taken from the resident/relative survey forms and also during the site visit. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self questionnaires that focus on the outcomes for people. The self assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. What the service does well: The manager and staff ensure residents receive care and support within a warm, caring and friendly environment. Residents appeared relaxed and comfortable with the staff and good communication was evident. During both days staff were observed spending a great deal of time with residents either on an individual basis or within a group. Care was seen to be given in a discreet sensitive manner and staff were patient and gentle in their approach. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents’ individual care needs and the level of support they required. Comments regarding the service from residents and relatives include: “Very good home” (relative) “Lovely staff (resident) St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 6 “A nice home to live in” (resident) “The girls are very good indeed” (relative) “It cannot improve as I believe it does most things well” (relative) “It makes the residents feel at home and provides entertainment and activities” (relative) Residents interviewed confirmed that the daily routine was flexible and based very much around their wishes. Residents said they could have a bath or shower at different times and that staff accommodated their wish regarding time of getting up or retiring at night. Residents’ care needs are assessed prior to arriving at the home to ensure staff can provide the necessary care and support. This is followed up with a comprehensive plan of care. Care documents seen identified individual health care needs and the completion of risk assessments to minimise any potential risk to the residents. This ensures a good quality of life for them with the support of the staff. Care plans seen were person centred and agreed by the resident and/or their relative. Through examining care records, general observation and talking with residents it was evident that staff had a good knowledge of individual care needs and that they enabled residents to make decisions and choice about their care and preferred routine. Evidence was seen of residents receiving the clinical support and care at the appropriate time. The manager had acted upon complaints/concerns and residents spoken with confirmed that they were confident that their views would be listened to and acted upon. Residents interviewed felt safe and supported by the overall management of the service. The service provides pleasant accommodation and areas seen were clean and decorated to a good standard. Residents had personalised their rooms and had been encouraged to see St Martins as their own home. Specialist equipment and adaptations, for example, special beds and moving and handling equipment were being used by staff to meet residents’ needs. Quality assurance systems are in place to monitor the service and the manager and staff work hard to continuously improve the overall care provision. This ensures a good quality of life for the residents. The manager is supported in her role by a good stable enthusiastic workforce and also senior management within Southern Cross. What has improved since the last inspection? Residents’ care plans are reviewed on a regular basis to ensure the information recorded is accurate and reflects changing needs. Medicines are administered safely to residents and in accordance with the home’s policy and procedure. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 7 Staff are recruited via robust procedures to ensure the ongoing protection of the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 8 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.V343465.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information regarding the service and pre admission assessments ensure staff can meet residents’ health and social care needs. EVIDENCE: The service user guide has been updated with the new manager’s details and the manager stated that this is made available for prospective residents and their relatives/representatives. There was plenty of information regarding the service in the main hall for people to view. A copy of the service user guide should also be displayed as this document had to be obtained from the computer. The service user guide provides comprehensive information regarding the service to enable residents to make informed choices. Residents are able to visit the home and have lunch with other residents and join in the activities in the afternoon. This enables them to get to the know the staff, residents already accommodated and to get a ‘feel’ for the service. Once a resident has taken up residency contracts are issued and these state the terms and conditions of residency and information regarding the care St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 10 provision. Those seen had been dated and signed by the resident and/or their relative/representative. The residential team leader and deputy manager complete a care needs assessment for all resident prior to admission. Assessments seen were for residents admitted since the last inspection and these had been completed to a good standard. The assessment document identified key areas including medication, dependencies, pressure areas, nutrition, mobility, personal hygiene, medical history, continence, risk of falls, social/family background, communication, bedroom comfort and mental state. Residents had also been asked about their sight, hearing, chiropody and dental needs, which are so important to the care of the older person. The assessment helps staff to collate the information for the plan of care and to assess any potential risk that may affect a resident’s welfare. Care management assessments had also been obtained from social services and staff liaise with family members to obtain as much information as possible. A resident said, “I was made very welcome when I came to the home, could not have been better”. Intermediate care is not provided at St Martins and this standard was therefore not assessed. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs were identified in a plan of care and medicines were administered safely to them. Residents were observed to be treated in a respectful manner. EVIDENCE: As part of the case tracking process five resident care files were viewed. Residents had an individual care file and the information was organised and available for staff and residents to view. Care documentation had been reviewed regularly to reflect changing needs and the resident and/or their relative’s agreement had been sought to the plan of care. A number of risk assessments had been completed as part of the care planning process and these identified any potential risk that may affect a resident’s well being, in areas such as, nutrition, moving and handling and care of skin. Management of risks addresses safety issues whilst aiming for a better quality of life for the residents. Care plans are based on residents’ individual care needs including key areas such as mobility, communication, personal hygiene, continence and nutrition. A plan of care is also recorded for any relevant medical condition or for any St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 12 specialist care or support needed. Pressure relieving equipment had been obtained for residents who spent long period in bed to minimise the risk of pressure sore development. Care needs for support with dementia were in place with associated risks for the effects of short term memory loss. Care plans seen gave good directions to staff to ensure continuity of care. It was evident that the health care needs residents were being met and the manager and staff did all they could to help people manage their own welfare if they wished to do so. Staff interviewed understood the importance of residents maintaining their own independence and making decisions and choices regarding their care provision. Care records evidenced that residents have access to a GP and appointments had been made with relevant health professionals. This was seen in relation to district nurse notes and a record of their treatment in their respective care files. A resident said, “The care is good here and the staff are ready to help me”. Likewise a relative reported, “The care could not really be better”. Medications are well managed and staff receive training in medicine awareness to ensure medicines are administered and recorded correctly. Training has been arranged for October 2007; a competency assessment should be completed for all staff who administer medicines to ensure they have the skills and knowledge to undertake this practice. A competency assessment was seen for this purpose. Medicine charts viewed evidenced that medicines are administered as prescribed and there is flexibility in the times medicines are given to make sure it is taken at the right time and also at the best time for each resident. A resident said, “I get my medicines on time and the staff make sure I take them”. Care plans recorded details of certain medicines to be administered, for example night sedation and medicines in liquid form, as these require specific management. There were no residents administering their own medications at this time however staff would support them with this practice. Medicines were found to be securely locked ensuring access is restricted to senior staff. The manager carries out a check on the medicines each month and paperwork was seen to support this practice. This audit is essential to show that medicines are being handed correctly and that staff remain competent in medicine administration. Staff were observed to assist residents in various care practices in a polite and helpful manner. Residents are asked their preferred name when they take up residency and whether they wish to receive care from a male or female staff member. Residents referred to staff as being professional, very friendly and respectful in their manner. Signs had been placed on bathrooms doors when occupied by the residents to ensure they were not disturbed. Staff spoken with explained how they promote privacy and dignity within their work. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise a great deal of choice and control over their lives and are offered a choice of well balanced and nutritional meals. EVIDENCE: St Martins presents with a caring friendly atmosphere and visitors were seen arriving at the home at different times of the day. A relative said, “I come in every day and the girls are always so friendly”. Residents are offered Holy Communion and members of the clergy visit so residents are encouraged to practice their religion as they wish. Care plans reflect relationships, religious and cultural needs in accordance with residents’ wishes. Residents were seen to be encouraged to maintain relationships by meeting with friends and family members within the privacy of their own rooms. An activities organiser has just over ten hours a week to provide a stimulating programme of social events for the residents. Residents interviewed were satisfied with activities offered however the time allocated should be extended to provide more quality time with each resident. This would assist with the development of one to one activities and also provide a fuller lifestyle for those residents who wish to participate more. The plan of activities was displayed in the main hall and there were a number of photographs on show from recent St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 14 social events. Activities include musical entertainment, bingo, painting, ceramics, cards and a summer fete. Residents have been invited to a summer ball in the past and also links with a local football club provide tabletop football games. The manager is looking to set up an activities committee to extend the range of social events that will include more trips out. Residents’ social participation had been recorded and with the assistance of the activities organiser residents are being asked to complete a life history. This will help staff to get to know the residents better however residents do not have to participate in this is they do not wish to. A two week menu was displayed in the main hall along side a nutritional rating for meals served. The menu should be placed in the dining room or in residents’ rooms as not all residents are mobile and therefore are unaware of what is on offer. Residents interviewed said that staff tell them what the menu of the day is however they would like to a see a menu and take more time choosing what they want to eat. Residents reported that generally the food was good however some thought the standard could be improved at times. Comments include: “Could be better” “OK most of the time” “You can have some thing else if you don’t want what’s on the menu” “Very good meals” “Nicely presented on the plate” Recent changes have been made to the menu in response to comments received ‘in house’ however there has been no audit of the food served to ensure it is to the liking of the residents. Specific requests for certain foods were brought to the manager’s attention at the time of the site visit. Food stores were satisfactory and there was plenty of fresh fruit and vegetables available. The dining room tables were attractively laid and there were flower arrangements on each table. Staff were observed to assist residents with their meals in an unhurried manner and a number of residents were having a late breakfast, which was their choice. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The manager using a complaint policy and procedure investigates complaints. A complaint log was evident and complaints or concerns received had been recorded in sufficient detail to evidence the nature of the complaint and action taken. All complaints are audited internally to ensure a full investigation is undertaken within a set timescale. The Commission has not received any complaints since the last inspection and residents and relatives interviewed said they had no concerns and were aware of whom to speak with should they wish to raise any issues. Staff interviewed knew the importance of taking the views of residents seriously. A staff member said they would report any worry or complaint to the manager immediately. A summary of the complaint procedure was displayed in the main hall and this should be updated with the new address for the Merseyside Commission’s office. Residents are registered on the Electoral Role and are able to retain their right to vote through the postal voting option or they can attend a local polling station. Advocacy details were on display in the main hall to enable residents and their families to contact the necessary body in confidence. Adult protection training has not been provided for all staff however a training session is planned for September 2007. Staff have access to an abuse policy St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 16 and also a copy of Liverpool and Sefton’s Guide to the Protection of Vulnerable Adults. Staff should be advised of the local document and referral to the local authority as part of the safeguarding procedures for reporting an alleged incident. Staff interviewed were aware of the concept of abuse and how residents’ rights should be protected. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,24,26 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained, safe and comfortable for residents to live in. This helps provide a good quality of life for them. EVIDENCE: St Martins provides comfortable clean accommodation. Areas seen were pleasantly decorated and residents had brought in items from home to make them bedrooms feel ‘homely’. There was plenty of equipment and specialist aids available to meet residents’ needs and make life easier for them. The lay out of the building allows residents to socialise in different communal areas; there are three lounges with a separate smoking lounge. This lounge complies with environmental health requirements. All three lounges had comfortable armchairs and coffee tables. The dining room is spacious and the majority of residents have their lunch here as it provides a pleasant setting. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 18 Bathrooms were clean, odour free and transfer tiles applied to the walls to make them more domestic in appearance. Residents have the use of a walk in shower if preferred. Liquid soap and paper towels had been provided in bathrooms, toilets and laundry. The laundry room was organised and well equipped. The staff to minimise the risk of cross infection were using gloves and aprons. The hairdressing salon is in need of painting and this should be included in the maintenance schedule of the building. This will improve the overall appearance of the room for the residents. The temperature of the hot water to the baths was being checked to ensure it was delivered to a safe temperature and emergency lighting was tested regularly as part of the fire safety checks for the building. This ensures the ongoing protection of people within the home. Records seen were current. There is a large enclosed garden to the rear and to the side of the building and these areas are becoming overgrown with weeds. General garden maintenance should be undertaken to ensure residents can sit in the garden in comfort at all times. There is also an inner courtyard with seating and flower arrangements. Again this needs some attention before it becomes overgrown. The home is situated on one level and there are ramps for access to the grounds. The corridors are spacious and grab rails are in place to assist residents with their mobility. A relative reported, “The building/setting is nice and well maintained”. Likewise a resident said, “I am fine about my room it has everything I need”. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A lack of staff training may place residents at risk. EVIDENCE: The staffing rota for the month of August 2007 evidenced sufficient number of staff on duty to provide care and support to the residents. Agency staff were in attendance at the time of the site visit to maintain staffing numbers. Residents interviewed said that there were sufficient numbers of staff on duty most days however on occasions staff were very busy and could do with extra help. Staff spoken with also confirmed this, as there are times when the dependency levels of the residents can be high. Comments from residents and relatives regarding the staff included: “Good staff” “Lovely caring people” “I have no complaints about the care” “Competent, friendly staff who support clients” (relative) “I can go home and not worry about my next of kin I know everything that needs to be done will be done professionally” (relative) NVQ (National Vocational Qualification) training at Level 2 and 3 ongoing for all staff. 52 have achieved a qualification in NVQ. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 20 A selection of staff recruitment files were examined and these included newly appointed staff. Staff had completed application forms and the files evidenced the necessary police checks and two written references, including a reference from a recent employer. Staff had been provided with a contract and job description. These details define the roles and responsibilities of the staff to assist them with their work. Effective recruitment procedures help ensure the delivery of a good quality service and protect the individual. New staff receive an induction and the Southern Cross induction record is in line with the Skills for Care Induction Standards. The induction is given over a period of time and new staff are supported in their role by senior staff. Staff interviewed confirmed that they received an induction when they started and were shown round the building. Examination of staff records and discussion with the manager and staff evidenced that the majority of staff require training in safe working practices to ensure staff have the skills and knowledge to provide the care and support to the residents. There has been little training since the last inspection and moving and handling is now out of date. The manager and operations manager compiled a training plan for staff during the site visit. This will provide courses for moving and handling, health and safety, first aid, food hygiene, adult protection and COSHH (Control of Substances Hazardous to Health). The training is to commence this month and continue through to October 2007. Other courses are also being arranged, for example dementia care, care planning, infection control and use of bed rails. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Martins is run in the best interests of the residents and they are protected by the policies and procedures that are implemented by the staff. A registered manager should be appointed. EVIDENCE: The manager Ms Joanne Goodwin has been working at the home for approximately nine months and has settled in to her new role. As part of the day to day management of the home the manager should be registered with the Commission for Social Care Inspection. Ms Goodwin must apply to the Commission for this position. Ms Goodwin has many years experience caring older people and has held previous management positions. Ms Goodwin is a registered nurse and also holds the Registered Manager’s Award. She will be attending the training in St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 22 safe working practices with the staff. Ms Goodwin takes an active part on an ethics committee and is a trainer for abuse and for a dementia course called ‘Yesterday, Today and Tomorrow’ which is being rolled out to staff In October 2007. Ms Goodwin is also attending a course for residents who require terminal care for non malignant conditions as part of her training plan. Ms Goodwin has worked hard with the staff to meet the requirements from the last inspection and to bring management stability to the residents and staff. This demonstrates good evidence of her experience and competencies to manage St Martins. Staff and residents interviewed said the manager was approachable and had an ‘open door’ policy. Residents and relative views are sought by surveys and the results are collated by head office and comments fed back to the manager and staff. A relative said, “Joanne (manager) checks with us that everything is ok and we can talk to her any time we want”. Comments from surveys refer to satisfaction for the service. The operations manager conducts monthly visits to the home to ensure the service is well run and to meet with residents and staff to obtain their views. Reports seen had been completed to a satisfactory standard. A regional financial administrator oversees financial records kept at the home to ensure resident finances are protected. A recent financial audit took place and recommendations made at that time have been implemented to benefit the residents. Financial records seen were maintained to a satisfactory standard. The manager has commenced formal supervision with the staff and staff meetings are held to enable the manager to update the staff with relevant information regarding the service. Good lines of communication were evident and care staff hold a key worker role, which allows them to have specific time allocated to spend with individual residents. Ms Goodwin has a clear understanding of the policies and procedures that are required for the service and these documents are made available to staff for their referral. All policies and procedures are updated via the company’s intranet site to ensure they meet current legislation. Equality and diversity is addressed through a number of policies including equal opportunities for staff, personal relationships, confidentiality, spiritual care and privacy and dignity for residents. Assessments and care plans are person centred and identify sexual needs, for example appearance, behaviour, religion and self image. Care was being provided in a way that meets the resident’s individual wishes and beliefs. Maintenance contracts for safe working practices and equipment were found to be up to date. A spot check of certificates was undertaken for the gas, electric, fire equipment, portable appliances and moving and handling equipment to evidence this. Fire alarms are checked weekly and a satisfactory test was carried out at the time of the site visit. Staff receive fire training and a session is booked for August 2007 for all staff. The manager is aware that this must be St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 23 given every six months. The fire risk assessment of the building is being updated to comply with the changes in the fire regulations. Accidents are recorded and monitored by the manager and staff. Health and safety risk assessments should to be updated in accordance with best practice and also current legislation. This will help protect people within the home. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 24 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 3 St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 25 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 OP30 Regulation 18 (1) (c) Requirement The registered person must provide training for staff appropriate to their work. Staff must receive training in moving and handling, first aid, food hygiene and infection control to ensure they have the skill and knowledge to undertake to provide care and support to the residents. Timescale for action 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. St Martins Refer to Standard OP1 OP9 OP12 OP15 Good Practice Recommendations The service user guide should be displayed for residents and relatives to view. Staff responsible for administering medicines should complete a competency assessment to evidence their skills and knowledge. The activities organiser should be allocated more hours to organise and develop activities for the residents. An audit should be undertaken of food served to ensure it DS0000025186.V343465.R01.S.doc Version 5.2 Page 26 5. 6. OP18 OP19 7. 8. OP31 OP38 is to the liking of the residents. Staff should be made aware of the Liverpool and Sefton’s Guide to the Protection of Vulnerable adults as part of their adult protection training. Maintenance of the grounds should be undertaken to ensure residents can use them at all times. The hairdressing salon should be painted to improve the overall appearance for the residents. A registered manager should be appointed for St Martins. Risk assessments for the building and safe working practices should be reviewed to ensure they are line with current legislation. St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Martins DS0000025186.V343465.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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