Inspection on 24/11/06 for St Martins

This inspection was carried out on 24th November 2006.

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

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

Other inspections for this house

St Martins 13/11/08

St Martins 26/01/06

St Martins 05/10/05

St Martins 09/02/05

St Martins 18/08/04

St Martins 24/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Martins Queen Street Gillingham Dorset SP8 4DZ Lead Inspector Alison Stone Unannounced Inspection 24th November 2006 10:00 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 DS0000026873.V315968.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 DS0000026873.V315968.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Address Queen Street Gillingham Dorset SP8 4DZ 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) 01747 823221 01747 826224 www.care-south.co.uk Care South Mrs Sandra Anne Lemon Care Home 32 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (32) St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 32 in the category OP (Old Age) including up to 6 in the categories DE(E) and/or MD(E). 26th January 2006 Date of last inspection Brief Description of the Service: St Martins is located near to the centre of Gillingham. The home is operated and managed by Care South, which is a ‘not for profit’ organisation operating a number of homes and care services across Dorset. Registration of the home is for accommodation of up to 32 older people over the age of 65 years, and up to six places can be used to provide a specialist service to older people with dementia or other mental health needs. Although the building is relatively old, it is well maintained and provides a range of comfortable accommodation for service users. There are five shared bedrooms and prospective residents are made aware if the vacancy on offer is a shared place. There is level access throughout the home and a passenger lift provides access to the first floor. Fees range from £425 to £515. This information was given on the 24th November 2006. Readers of this report may find it helpful if they have any queries about fees to contact the Office of Fair Trading www.oft.gov.uk. The acting manager said that up to date inspection reports are available in the home’s office and copies can be provided on request. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of this care home by the Commission for Social Care inspection this year, the inspection year runs from 1 April 06 to 31 March 07. This was a key inspection. The key standards are identified in the main body of report in each outcome area. In order to obtain a fuller picture of the home the reader should refer to the earlier inspection report dated 26th January 2006. During the visit which lasted six and a half hours the inspector spoke with three service users, the manager, the deputy manager and three staff members. The inspector joined service users for lunch, undertook a tour of the premises, observed practice and looked at medication supplies. She inspected records relating to service users’ care, staffing and medication and other documentation relating to the running of the home. Preparation work included, reading, collation and analysis of surveys and comment cards and reviewing of the Pre Inspection Questionnaire sent to the manager prior to the inspection being completed. The Commission received 25 comment cards from service users, nine from relatives/friends, five from health care professionals, including GPs and two from social care professionals. The manager and deputy manager were present during the inspection. The manager provided the inspector with all the relevant information relating to the inspection and any necessary background information. Feedback was given to the manager and deputy manager at the end of the inspection. Of the 38 National Minimum Standards, all 22 Key Standards and 5 of the remaining 16 Standards were assessed. The inspector would like to thank everybody who contributed towards the inspection process. What the service does well: The manager ensures that service users are only admitted to the home after they have been supported with a comprehensive pre-admission assessment to ensure the home can meet their needs. Service users and relatives said that they were given lots of information about the home before moving in. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 6 Service users are supported with introductions to the home to see what it is like before making decisions about whether they want to live there. Care plans are generally detailed and provide staff with up to date information about people. They were noted to have been completed with the service user and had been regularly reviewed. The home is well supported by the local primary health care team and GP practice. One GP commented that the home provides “high standards on a consistent basis”. The home’s medication management is generally robust and protects the service users. Service users are supported with choices about their health care and can access community health services as well as being offered this service within the home. Service users are encouraged and supported to make choices and decisions as far as they are able. Staff promote service users’ independence by encouraging them to do as much for themselves as they are able. Meals are of a good standard and people are supported to eat their meals in a pleasant area at times they choose. Service users are offered a choice of nutritional well-balanced meals. Service users made comments like “the food is excellent”, “Wonderful, the meals here are wonderful”. Service users and staff say that they feel supported by the manager and they are able to approach her with any issues and have confidence that she will deal with issues appropriately. The manager is experienced and runs the home in the best interests of the service users. What has improved since the last inspection? There were two requirements and three recommendations made at the last inspection. The two requirements and three recommendations have been met. A further three requirements and one recommendation were made at this inspection. The home has improved in some of the areas identified in the last inspection, the areas that the inspector found improvements in are summarised in this section of the report. Care plans had been regularly updated and reviewed to reflect service users current needs. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 7 Recommendations about some staff practices in relation to medication have been addressed. It was noted that there were better staff practices in the area of PRN medication and the information recorded on medication administration charts. However it was noted during this inspection, that further improvements are required. The recommendation in relation to information held on staff files has been addressed. However it was noted on this inspection further improvements in this area are required. 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 DS0000026873.V315968.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 DS0000026873.V315968.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): 1, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are supported with adequate information to make an informed decision about whether they want to live at the home. Service users can be confident that the home can meet their care needs prior to them moving in, because the home undertakes comprehensive assessments. Service users and their families/representatives are actively encouraged to visit the home and spend time there. Assessing the quality and suitability of the home’s facilities before making a decision about whether they would want to live there. The home does not provide any intermediate care, or has plans to do so. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 10 EVIDENCE: Five service users records were reviewed as part of the inspection. These indicated that in all cases where a service user was funded by social services a thorough assessment of their needs was undertaken prior to a referral being made to the home. When a service user is referred to the home the manager and/or deputy manager visit the prospective person to carry out their own assessment of need. The review of these documents indicated that these were comprehensive assessments that included all the service users basic information as well as information about their physical, social and psychological needs. The assessments were noted to involve relatives and social care and/or health professionals. These documents had been regularly reviewed. Service users and families spoken to as part of the inspection indicated that they had been given lots of information about the home prior to moving in. This included information about the facilities in the home, activities, room sizes and details about how to make a complaint. The manager was able to demonstrate that all new service users were supported with packs of information relating to the home including a copy of the Service Users Guide. Service users spoken to indicated that they felt they had been supported with visits to the home before having to make a choice about moving in. A relative said that they had been involved in all introductory visits to the home before their family member moved in, further supported this. At one point during the inspection the manager left to meet with a prospective service users family and show them around the home. Service users records indicated that after a period of six weeks they are supported to have a review. Records indicated reviews included all involved parties like service users relatives and/or representatives. The reviews looked at how the person had settled in and whether they were happy and if the home was meeting their needs. St Martins DS0000026873.V315968.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): 7, 8, 9 & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users health needs are detailed in their care plans and service users can be confident they will receive the support they require to meet their care needs. Service users best interests are generally protected by the homes policies and practices in relation to medication. However some minor adjustments are required to ensure robust staff practices. EVIDENCE: As part of the inspection five service users records were looked at. These were found to be very detailed. Care plans described the care to be provided and detailed service users preferences. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 12 Work had been undertaken through the assessment process to identify a service user’s interests and hobbies, their life history and their friends and family relationships. Weight charts were in place and it was noted that where there had been concerns about a service user’s weight, staff had taken the appropriate action. Assessments had been undertaken of skin care and there were records detailing the assessment undertaken in relation to a service user’s dementia. Records of regular reviews were also seen on service users’ files. The manager was able to demonstrate that relatives are involved in service users’ plans of care and are regularly consulted with. Families spoken to during the inspection supported the fact that staff kept them informed about their relatives care. The home’s medication management was reviewed as part of the inspection. It was noted that recommendations made at the last inspection had been taken on board and there were improvements. However further improvements are needed to ensure a robust medication audit trail. New medication administration charts should detail the number of remaining prescribed tablets left and this should be recorded on service users new medication administration charts. All the relatives that were involved in the inspection process made positive comments about standards of personal care their family members receive. Service users were observed to be well dressed and were smartly presented. It was noted that service users had nicely styled hair. Service users spoken to said they enjoyed going to the hairdresser who visited the home. Service users and families contacted as part of the inspection process all spoke positively of the care and support they receive at the home. Service users said that they felt they were offered choices and staff respected their wishes. Direct observations made during the inspection noted staff encouraged service users to do as much for themselves as they could. Staff were seen to offer service users choices about their meals and activities. St Martins DS0000026873.V315968.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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally service users are supported to have access to a lifestyle in the home that meets their interests and preferences. The home supports and encourages people’s social, religious and recreational interests. Service users are supported to maintain contact with family and friends. They are supported and encouraged to be part of the local community. Service users are supported by staff to have choice and control over their lives. Service users receive appealing well balanced meals in a pleasant dining area. EVIDENCE: Service users and their families completed a profile in the assessment that details information about individual cultural, social and leisure interests. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 14 The home used to have an activities coordinator. However this post has been vacant for some time now. The manager assigns a member of staff to lead on service users activities each day until this post can be filled. The service users notice board demonstrated details of regular weekly activities as well as a large programme of activities arranged for the Christmas period. Two of the service users spoken to said there were always lots of activities over the Christmas period. During the inspection service users were noted to be encouraged to take part in activities. One service user was being supported by a member of staff to make up a list of Christmas presents they would like their key worker to buy to send to their daughter in America. One family commented that they felt since the absence of an activities cocoordinator there had been a lack of activities available for service users to take part in, particularly in the evenings and on weekends. Three service users commented in the returned postal questionnaires they would like to have the opportunity to take part in more activities, particularly going out for walks. The service encourages regular family and friends contact and supports family involvement. The manager said service users are encouraged to be part of the local community. During the inspection it was observed that service users were encouraged to entertain their friends and relatives in the communal areas of the home. The facilities provided in service users rooms are pleasant and provide a comfortable, nicely furnished space to receive guests. However it was noted that there was little or no private space for service users to meet with their family and/or friends other than a small staff room and their own bedrooms. Some of the service users also share their bedrooms. Staff and service users spoken to agreed that there were regular service user meetings at the home. Staff also said that they felt that there was an effective key worker system in place to support service users with their individual needs. One mealtime was observed during the inspection. This was noted to be a very pleasant social experience, where service users were supported by staff to enjoy their meal times. Staff spent time encouraging service users to make choices for themselves and were seen to offer service users discreet support where required. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 15 Service users seemed to really enjoy their meal times, chatting amongst themselves. Meals were pleasant and unhurried. The home benefits from a catering department and the chef ensures service users dietary needs are taken account of. Service users are offered a choice of meals, including main courses and desserts. All meals are served with a choice of drinks and the meals are well balanced and well presented. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 16 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. Service users and their relatives can be confident that their complaints will be listened to and taken seriously. The home has a complaints process in place that supports the management of any complaints. Service users are protected from abuse and neglect through a process of, staff training in this area, the home’s policies and an open management style. EVIDENCE: The review of the pre-inspection questionnaire indicated that there had been one complaint made since the last inspection. Information pertaining to this complaint was looked at during the inspection. This demonstrated that the complaint had been appropriately managed in accordance with the homes procedure. The home has a complaints procedure in place; this was made available to all service users in the Service User Guide. There have not been any complaints made to the Commission for Social Care Inspection in relation to the service the home provides. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 17 Services users spoken to during the inspection said that they would feel confident to make a complaint to the manager. They said they felt she was supportive and interested in their suggestions, concerns and/or complaints. Four staff records were reviewed as part of the inspection. These indicated staff had been supported to undertake training in the areas of Protection of Vulnerable adults. Staff spoken to during the inspection were able to demonstrate a basic awareness of the different types of abuse service users may be at risk from and what they should do if they had any concerns. The manager was able to demonstrate that she had the appropriate policies and procedures in relation to Adult Protection on the premises. Both the local Social Care and Health’s policy and the organisation’s own policy were available at the home. The review of staff files indicated that where there had been any concerns with staff practices these had been addressed with the staff members and any required follow up action had been taken. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 18 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, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortably nicely furnished and decorated home. The failure to appropriately risk assess and make the necessary arrangements to cover a radiator in a service user’s bedroom places service users at risk. Service users’ bedrooms are pleasantly decorated and furnished reflecting their personal tastes and belongings and the rooms meet their needs. The home is clean, tidy and hygienic. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 19 EVIDENCE: During the inspection a tour of the premises was undertaken. This included looking around all the communal areas including the dining room and lounges, bathrooms and toilets. The home’s medication room, kitchen and pantry area and laundry room were also looked at. With the permission of the service users, three occupied bedrooms were looked at, a further two empty bedrooms were also looked at. It was noted during the review of service user’s records that risk assessments had been undertaken of the environment and generally the appropriate action had been taken to ensure service users’ communal and bedroom areas were free from risks. However it was noted in one service user case, whilst the appropriate risk assessment had been undertaken and steps taken to manage the risk, these had not been effective and the risks of scalds to the service user from an uncovered radiator in their bedroom remained a serious concern. After discussion with the manager about this risk, she took immediate action to urgently request this radiator was covered. Service users’ bedrooms were nicely decorated and each room reflected a different style of décor. The manager said that the staff work with service users and their relatives to find out people’s preferences and tastes and make sure rooms reflected a person’s individuality. Service users’ bedrooms included furniture and fittings they had brought from their own homes and it was noted that there were many personal effects around the rooms. Service users were able to have a television in their own bedrooms. In the case where bedrooms were shared, consideration had been given to each person’s individual tastes and privacy. The manager said often service users who share a room prefer this as they like the company of another person. A service user who currently shares a room agreed that they preferred to share a double room than have a bedroom to themselves. The manager said that due to the lack of private communal space, one of the bathrooms was now used as a room for individual treatments like hairdressing and health checks. However it is evident that the previous use of this room was a bathroom and the room is cluttered and does not lend itself to a pleasant private area for people to use and enjoy. Given the general lack of private communal space for service users to use, it is recommended that consideration is given to how best the home could meet service users’ needs in this area. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 20 During the inspection the home was noted to be clean and tidy and free from any unpleasant odours. The manager said that there are three domestic assistants employed at the home; they work various shifts covering a seven day period. It is their responsibility to ensure the home remains well maintained. It was noted that hygienic facilities in service users’ toilets and bathrooms were inadequate. In one bathroom the toilet seat needed replacing as it was chipped and the seal was broken. Hand washing facilities in communal bathrooms comprised of communal soap bars and towels. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Service users are supported by skilled and trained staff, who are encouraged by the organisation to undertake regular training, so service users can feel confident that staff are competent in the support they provide. Service users can be confident that there are regularly enough staff on duty to meet their needs. Service users can be confident that the home’s recruitment practices are mainly robust. EVIDENCE: Four staff files were reviewed as part of the inspection process. The manager provided the inspector with documents that demonstrated there was a staff training and development matrix in place. The policy of the Organisation that owns St Martins (Care South) is to register staff on the NVQ 2 programme once they have successfully completed their probationary period. The pre inspection questionnaire states that eight staff St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 22 currently have their NVQ 2 qualification. This number represents 32 of the staff team. This figure is lower than the Government requirement that 50 of the work force will hold an NVQ qualification or equivalent by the year 2005. Staff are supported with training both in mandatory and statutory areas. Staff records indicated that they were supported to undertake training in areas like fire, infection control, protection of vulnerable adults, manual handling, first aid, health and safety, food hygiene, care of the terminally ill, dementia awareness, the ageing process, diabetes, fostering people’s rights and responsibilities and promoting effective communication and relationships. These topics are covered during the induction period and the manager said that the staff induction is now in line with the ‘Skills for Care’. The manager was able to demonstrate that staff had individual training records in place, supplementary to this staff supervision records showed that staff training needs were discussed during supervision. The manager ensured staff regularly updated their skills and knowledge through a training matrix system. Staff spoken to say that they were offered regular training. Staff rotas and conversations with service users indicated that there were enough staff on duty on a daily basis to meet the needs of service users who live at the home. The examination of staff files indicated that generally recruitment practices in these areas were robust. However three out of four staff files only had one written reference in place. Records indicated that two references had been applied for. The deputy manager said that this was an oversight on her part and she had sent the originals to the organisations head office and neglected to put a copy on the individual staff file. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 23 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 service users benefit from having an experienced registered manager who manages the home efficiently and in the best interests of the people who live there. The open management enables service users and their family and/or friends to feel confident about raising issues. The home has the necessary arrangements in place to safeguard service users financial interests. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has many years experience of managing care homes and has a social work qualification. As mentioned in the last inspection report she will not be undertaking a NVQ 4 qualification at this stage of her career. In order to meet this standard in full the registered manager has to attain this qualification. The manager keeps abreast of current practice by undertaking training periodically in topics that are related to health and safety and to the care of older persons. The deputy manager is currently undertaking the registered manager’s award at NVQ level 4. There are clear lines of responsibility with regard to the management of the home. Representatives of the Care South management team in compliance with regulations make regular monitoring visits to the home and copies of reports made are sent to the Commission. The home operates a quality assurance process and has a policy in this area. The manager was able to demonstrate that regular staff and service users’ meetings take place. These meetings are minuted. Service users spoken to said that they felt they could approach the manager with any concerns. The staff expressed their confidence in the competence of the manager and deputy. One staff member said that they felt supervision and staff meetings were really useful as they felt their views were listened to and affected changes in the home. The home has policies and procedures that relate to the management of service users’ finances. Three service users’ financial records were looked at during the inspection and these were found to be in good order. Small amounts of cash and/or valuables can be kept in a secure place for service users. Records are kept of all transactions and receipts are retained. It was noted during the tour of the premises that lockable facilities are provided in service users’ own rooms. The inspection of fire records showed that staff regularly test the fire equipment and regular fire drills take place. Staff have received fire training and the manager is aware of the new fire regulations and has put into place the appropriate risk assessments in line with the new rules around fire prevention. Risk assessments are in place for staff, the premises and food safety. The manager said these are regularly reviewed, at least annually. As part of the inspection the kitchen area was looked at. This area was found to be clean and St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 25 hygienic, with foodstuffs stored appropriately. The manager said that they have regular visits from the environmental health officer. It was noted that there was an up to date portable appliance testing certificate in place, along with the appropriate five-year hard wiring check. There was also an up to date gas landlord certificate in place. Water temperatures are checked each time service users have a bath to ensure that the water is at the appropriate temperature. Records relating to the testing of water indicated that all the appropriate checks and risk assessments had been undertaken. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 26 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X 18 3 2 X X X 2 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 27 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 OP25 Regulation 13(4)(a) (b)(c) Requirement Timescale for action 24/11/06 2. OP26 16(1)(j) The registered person shall ensure that(a) all parts of the home to which service users have access are so far as reasonably practical free form hazards to their safety; (b) any activities in which service users participate are so far as reasonably practical free form any avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. (This relates to the uncovered radiator in a service users bedroom, which was presenting a scald risk.) The registered manager must 24/02/07 ensure after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. (This refers to the hand washing and drying facilities within the toilets and bathrooms, and includes the damaged toilet seat in the downstairs bathroom). DS0000026873.V315968.R01.S.doc Version 5.2 St Martins Page 28 3. OP29 19(1) Sch 2&4 The registered person shall not 24/02/07 employ a person to work at the care home unless(a) the person is fit to work at the care home; (b) subject to paragraph (6), he has obtained in respect of that person the information and documents specified in(i) paragraph 1 to 6 of Schedule 2; (ii) except where (7) applies, paragraph 7 of that Schedule; (iii) where paragraph (7) applies, paragraph 8 of that Schedule; and (c) he is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person. (This relates to two written references for staff not being available on their individual files.) (i) 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 OP9 Good Practice Recommendations The registered manager should ensure a record is maintained of current medication for each service users. St Martins DS0000026873.V315968.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000026873.V315968.R01.S.doc Version 5.2 Page 30 - 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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