Inspection on 24/04/07 for St Martins

This inspection was carried out on 24th April 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 26/06/08

St Martins 02/05/06

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 Unannounced Inspection 24th April 2007 09:10 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.V334949.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 DS0000015469.V334949.R01.S.doc Version 5.2 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.V334949.R01.S.doc Version 5.2 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 with dementia over the age of 65 years of age. (total not to exceed 28). 2nd May 2006 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 twentyseven 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 £340.40 to £546.00 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 23 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.V334949.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for seven hours and twenty-five minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff a visiting relative and a visiting friend. As part of this inspection surveys were sent to twelve residents, nine relatives, four General Practitioners, four health and social care professionals and ten of the homes staff. Four residents surveys were returned and included comments that the home is always clean and fresh and that they are very happy at St Martins. Four health care professional surveys were returned and comments includes that they are satisfied with the care provided. Three relatives surveys were returned and comments included that the home is clean, friendly, provides good food and the staff are very nice and that visitors are always made welcome at anytime. One of the relatives’ surveys stated, “all aspects of care and well-being are thoughtfully considered at St Martins and it has a good atmosphere and is one of the best homes in Southend”. Four staff surveys were returned and comments were made on how supportive the manager is and that she is always available. Twenty-seven of the thirty-eight standards were inspected. What the service does well: The home benefits from good leadership and well trained and supervised staff. St Martins offers a vast range of activities and has regular events scheduled throughout the year that includes singers and dancers and “Down Memory Lane” a visiting museum. The home consults its residents, relatives and staff on a regular basis to obtain their view on how the home should be run. St Martins has achieved the top level in their quality assurance system. The menus offer a good choice of foods selected by the residents, meals are healthy, appetizing and plentiful. The dining area is spacious and pleasant and tables are nicely laid out. The home is clean and decorated to a high standard, repairs are dealt with quickly and furniture is of a good quality and replaced when necessary. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000015469.V334949.R01.S.doc Version 5.2 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.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out a thorough pre-admission needs assessment and provides prospective residents with sufficient information to enable them to make an informed choice. All residents are provided with a written contract of their terms and conditions with the home. EVIDENCE: The home has a copy of their Statement of Purpose available in the hallway; this copy was dated 2004. The manager said that this document is currently being reviewed and the 2004 copy would be replaced with the new version after being agreed by the Committee in May 2007. All of the care files examined contained copies of resident’s contracts with the home. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 9 The pre-admission assessment documentation evidenced that a full assessment of needs had been carried out prior to admission. On one of the care files examined the pre-admission assessment documentation had not been fully completed and the resident had not been sent written notification that the home could meet their needs. The manager said that this had been an oversight on her part and that she would ensure this did not occur again. St Martins does not provide intermediate care. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes care plans contain all the information required to meet resident’s health, personal and social care needs. Health care needs are fully met. Medication policies and guidelines are good but some of the practices used are not acceptable. Residents are generally treated with respect and their privacy and dignity upheld. EVIDENCE: All of the care files examined contained detailed instructions of how individual’s care would be provided. The care plans are reviewed on a monthly basis and any changes recorded and implemented, ensuring that residents health, personal and social care needs are constantly met. Residents spoken with confirmed that they were well cared for and that staff always checked with them with regards any change of needs. Details of health care appointments are recorded in the care file and the outcomes of any appointments are recorded in the daily notes. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 11 The home has a clear medication policy and guidelines. The homes system of ordering, storing and returning medication is good. Regular audits are undertaken on a daily basis and errors are identified and rectified swiftly. The medication records inspected were clear and accurate and any changes were appropriately recorded on the reverse of the MARS (medication administration record sheet). Appropriate coding was used for any medications not administered. The staff member administering medication on the day of the inspection administered a residents eye drops at the dinner table whilst the resident was eating their meal and did not wash her hands or wear disposable gloves and then continued administering other resident’s medication. It is not appropriate to administer eye drops at the dinner table whilst a resident is half way through their meal. Staff should follow the homes infection control policies and ensure that their hands are washed before and after the administration of eye drops. Residents are addressed by their preferred name, which is documented in their care files, and one resident spoken with confirmed this. Residents spoken with said that they felt well treated and that staff showed them respect and asked them what they wanted and needed. Staff interacted well with residents and took time when explaining things to them and ensured that the resident felt comfortable with the request before taking any action. Residents spoken with confirmed that they were able to see their visitors in private if they wished and relatives spoken with confirmed this. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents experience a lifestyle that matches their needs and they are encouraged to maintain contact with their families and friends. Residents are helped to exercise choice and control over their lives. The home provides a wholesome appealing balanced diet in spacious pleasing surroundings. EVIDENCE: The pre-admission assessment identifies the resident’s likes, dislikes and preferences and gathers a social history that includes any particular hobbies or pastimes they have enjoyed. The home ensures that it gathers as much information as possible and involves relatives and friends, where residents are unable to provide the information themselves. The home offers a large range of activities including a list of scheduled events that take place regularly and include an American sing-a-long, Egyptian dancers, garden parties, rock and roll sessions, cream teas, cockney evenings and a mobile museum. Residents spoken with confirmed that they enjoyed most of these events. The home is in the process of making themed areas including a seaside theme, a country theme and a Hollywood theme. This is progressing well and the library and St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 13 reminiscence areas are now complete. Residents spoken with commented on how interesting the reminiscence area is and how they enjoyed visiting it. Residents, relatives and a friend spoken with said that the home always makes them feel welcome and they are able to visit in private if they wish. The home holds residents meetings every two months and the topics discussed included activity sessions, the themed corridors, meals, outings, news reports, chef interviews and the need to calibrate the weighing scales. Residents spoken with confirmed that they enjoyed the meetings and said that they were kept informed of all matters with regard to their home including information on any donations that had been made. The home is in the process of collating photographs of food items and plans to compile a pictorial menu. A new chef has been appointed and the home is awaiting clearances for them and expects them to start work within the next few weeks. There is currently one cook who is supported by agency staff when necessary. The menu offers two choices daily and an alternative will be provided if required. On the day of the inspection the food chosen by residents was as described on the menu and looked appealing. The menu is nutritious and varied and residents said that they enjoyed a good range of different foods. The dining area is large and well equipped and the manager said there are plans in progress to redecorate and refurbish the room to offer better storage and more updated furniture. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home listens and acts upon complaints swiftly. Staff are trained in the Protection of Vulnerable Adults and residents are protected from abuse. EVIDENCE: The home has a good clear complaints procedure that is regularly reviewed. There has been one complaint in the last twelve months that has been dealt with by the home in a satisfactory manner and appropriately recorded. Residents and relatives spoken with confirmed that they were aware of what to do if they wanted to complain. St Martins has a clear Adult Protection policy that works in line with the Southend Borough Council’s Adult Protection procedure. All staff has received training in the Protection of Vulnerable Adults and further updates are due later this year. Staff spoken with had a good awareness of the homes procedure. The home has one POVA issue that is currently in the process of being investigated. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe well-maintained environment with sufficient communal facilities that are clean, pleasant and hygienic. EVIDENCE: St Martins is a large home with plenty of seating areas; there are two large lounges, a large conservatory that overlooks an attractive garden and several small themed seating areas including a reminiscence room and library. The home is well decorated and there is an on-going plan for refurbishment and decoration. The medication/treatment room now has air-conditioning installed and the conservatory roof has had solar film fitted to make the room more comfortable. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 16 The home is in a good state of repair and has sufficient communal facilities for the current resident group. The garden is laid to lawn with flowerbeds and a pathway; the manager said that there are plans to extend the pathway so that it forms a circle around the whole of the garden. Residents spoken with said that they really enjoyed the garden and that it was lovely to sit in the summer. The outside space at the home was clean, tidy and very attractive. The summerhouse is currently storing the Christmas decorations; the manager said it is her intention to remove these soon as the summerhouse will be in use throughout the summer months. Residents were observed walking and sitting in the garden throughout the day. All of the bedrooms were nicely laid out with good quality furniture and fittings and had many residents’ personal items in them. Residents spoken with said that they were encouraged to bring their personal belongings to the home. The home was clean pleasant and hygienic. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this 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: St Martins staff rota reflected the staff on duty on the day of the inspection and identified each staff role. One senior carer and four care staff were on duty throughout the day; in addition to this there were sufficient domestic and catering staff. The manager and deputy manager worked in addition to the care and ancillary staff. Five staff have completed their NVQ training, one staff is in progress and a further seven staff are due to start this year. Three staff files were examined and contained evidence of staff training and induction. Two of the staff files examined was for staff that had worked at the home for many years and did not contain all the relevant documentation as detailed in Schedule 2 of the Care Homes Regulations. On checking other more recent staff files most of the requirements under Schedule 2 were met, however there was no evidence of a workers physical and mental fitness. The home must obtain evidence that each of its workers are physically and St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 18 mentally fit for the work they are to do and this should be kept on staff files. One of the recent staff application forms examined did not contain enough information on the employees work history therefore any gaps in employment could not be identified or explored. A thorough work history must be obtained and any gaps explored. Staff undertakes a wide range of training, which includes regular updates, and refresher training. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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, however there was an oversight in checking the electrical systems inspection certificate. EVIDENCE: The manager is a Registered General Nurse and has managed the home since April 2004 and has recently completed her NVQ management qualification. There has been some problems with the training provider and the manager is currently awaiting certification for her completed work. The trustees of the home support the manager in making continual improvements to the building St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 20 and the way in which the home is run. There is a business plan in place for 2007-2008. The home completed level 3 PQASSO (Practical Quality Assurance System for Small organisations) in March 2007. PQASSO is a quality assurance system set up for small charities and voluntary organisations. In addition to this the home carries out its own quality surveys in which residents, relatives, visitors and staff have the opportunity to express their views. The manager compiles a report of the survey findings and provides a copy to all the relevant people including the CSCI. The homes quality assurance system does not include obtaining views from General Practitioners, Care Managers or other professionals. The manager said that she would include professionals when the next survey is undertaken. The home does not hold residents monies, the residents and their families deal with their finances. The last electrical safety test in 2003 identified that some work needed to be carried out and this was done swiftly. There was evidence from the electrical contractor to confirm that all of the work had been carried out as required. On checking the safety certificate it was advised that the system be inspected again within one year. The manager said that this had been an oversight as generally the electrical system was inspected every five years and that she would arrange another inspection immediately. Safety certificates must be read thoroughly when issued, to ensure that the home complies with their requirements. Other safety certificates for equipment and services were inspected and were all up to date. The home carries out regular fire drills and fire checks and has recorded evidence of this. All staff has received health and safety training and the home provides regular updates. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 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 2 St Martins DS0000015469.V334949.R01.S.doc Version 5.2 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 OP9 Regulation 13 (2) Timescale for action The registered person shall make 30/06/07 arrangements for the handling and safe administration of medicines in the care home. This refers to the administration of eye drops at the meal table whilst a resident was eating their meal. 2. OP9 13 (2) The registered person shall make 30/06/07 arrangements for the handling and safe administration of medicines in the care home This refers to the staff member not washing their hands between administering medication to one resident and eye drops to another. 3. OP29 19 (b) (i) 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 evidence that each person St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 23 Requirement 30/06/07 working at the home is physically and mentally fit for the work. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations The home should ensure that any gaps in employment on the application form are explored and recorded. St Martins DS0000015469.V334949.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 DS0000015469.V334949.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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