Inspection on 25/10/05 for St Martins

This inspection was carried out on 25th October 2005.

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

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

Other inspections for this house

St Martins 26/06/08

St Martins 24/04/07

St Martins 02/05/06

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 Mr Ron Reeves Second Inspector – Pauline Marshall Unannounced Inspection 25th October 2005 11:00 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 DS0000015469.V256278.R01.S.doc Version 5.0 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.V256278.R01.S.doc Version 5.0 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.V256278.R01.S.doc Version 5.0 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. Personal care to be provided to no more than 28 older people over 65 years of age. (total number to not exceed 28). 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 service users wih dementia over the age of 65 years of age. (total not to exceed 28). 3rd June 2005 Date of last inspection Brief Description of the Service: St. Martins is a large older style detached home situated in a pleasant residential area in Westcliff on Sea. The home is close to public transport and local shops. The home provides accommodation and care for up to twenty eight 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. Accommodation is on three floors with a shaft lift provided. Accommodation comprises of 22 single and 2 double bedrooms, 6 of which have en-suite facilities, there are two separate lounges, a large dining room, a room for visitors and a conservatory lounge which leads out to a large well maintained attractive garden. There is limited parking to the front of the property. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which was carried out by two Inspectors and lasted for five hours. During the inspection the Inspectors spoke with manager, deputy manager, five residents, five staff and a visiting relative. There was a tour of the building and inspection of a sample of policies, procedures and records. What the service does well: What has improved since the last inspection? What they could do better: Minor improvements are required to the home’s daily recordings to ensure they fully record the welfare of the resident, how they spent their day and the progress of the care plan. Further development of the service provided to residents who have dementia were discussed with the manager. The home must ensure the agreed plans to upgrade the bathrooms, toilets and sluice room should take place. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 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.V256278.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The admission process is well managed and prospective residents and their families are given adequate information and the opportunity to visit the home in order to make an informed choice. EVIDENCE: The home’s Statement of Purpose and Service Users’ Guide was found to be appropriate at the previous inspection. Examination of care plans revealed that the home carries out detailed preadmission assessments. Prospective residents are invited to visit the home as many times as they wish before making a decision. Before admission each prospective resident is informed in writing that the home can meet individual needs. Each resident is issued with a contract detailing the terms and conditions residency. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 9 A visiting relative confirmed that her mother had a pre-admission assessment and that the home are meeting her mother’s needs very well. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 Residents’ personal and health care needs are consistently being met. Appropriate systems are in place for the administration of medication. EVIDENCE: Care plans evidenced that residents’ personal and health care needs are being met. Care plans included detailed risk assessments covering all assessed needs. Improvements to daily recording were discussed with the manager. The manager informed that approximately 75 of the residents are suffering from various degrees of dementia. Positive discussions were held with the manager and her deputy regarding further development of the services provided for dementia sufferers. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Daily routines are flexible and daily activities varied and depend on individual needs and choices. Visiting arrangements are open and relaxed. Dietary needs of the residents are well catered for, offering a well balanced and varied menu offering choices. EVIDENCE: Residents’ social history, including their likes and dislikes, are obtained during the admission process with the assistance of relatives where necessary. A variety of activities are provided. Residents make suggestions at their regular meetings. A resident is deputy chairman and organises meetings and takes the minutes, types them on his computer and distributes them. Staff organise activities on a daily basis outside to their normal shift. In addition, major events both inside and outside the home are arranged. It was noted that ten events had been arranged leading up to Christmas. Residents said they can have visitors at anytime and they are always made welcome by the staff. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 12 One of the many strengths of the home is the provision of meals. A wide and varied menu including choices of menu, meal and tea. Every resident is asked each day what they would like from the menu and can always request alternatives to the menu if they wish. The meal of the day was seen to be well presented, appeared appetising and in good portions. The inspectors spoke with a number of residents throughout the day. Comments included:“Can have visitors at anytime, the staff are very nice to the visitors.” “I have a very nice room – designed for me.” “The food is very good and you can always have an alternative.” “The home is wonderful – have a nice room, the staff are very good, food is wonderful, you can do whatever you like, really easy going here.” St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Arrangements for protecting vulnerable residents and responding to their concerns were satisfactory. EVIDENCE: The home has appropriate policies, procedures and practices for dealing with residents and relatives concerns. Two complaints had been received by the home since the last inspection. Both were dealt with by the home in a satisfactory manner and appropriately recorded. All service users where possible are included in the local voters register. The manager informed that some residents have postal votes, some are escorted by the staff and others by their families to vote. All staff have completed training on the protection of vulnerable residents. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-21,23-26 The home provides a good standard of accommodation to residents, which is homely, comfortable and maintained to a high standard. EVIDENCE: The home is a large older style detached house. There are a variety of comfortable communal areas, including two large lounges, a visitor’s room and a large conservatory, which leads to an attractive well maintained garden. Bedrooms were seen to be well furnished and decorated. There are sufficient bathrooms and toilets provided. A plan has been agreed to redesign and upgrade bathrooms and toilets and reposition sluice room. Commencement of the work is dependent on raising the capital expenditure. Residents commented that they were very satisfied with their rooms. resident commented that the home “is spotlessly clean.” One St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Staffing levels and skills were appropriate to meet the needs of the residents. A wide range of relevant training is available and NVQ training promoted. EVIDENCE: At the time of the inspection there were adequate staff on duty to meet the needs of the residents and staff rotas indicated that agreed levels of, one senior and four care staff on duty during the day were being maintained. In addition, sufficient catering and domestic staff are employed. Records indicated a wide range of training is made available to staff with twelve staff undertaking NVQ level 2 training. Staff spoken with expressed their appreciation of the varied range of training provided by the home. They also felt they had a good staff team that works well together. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 Significant improvements have been made by the manager and her deputy in improving the quality of care and staff morale. The home now benefits from stable leadership, which enables the home to provide a consistent high quality of care. EVIDENCE: The manager is a RGN and has managed the home since April 2004. She is currently undertaking training at NVQ level 4. It was evident that the manager supported by her deputy have made significant improvements to the service. They have both been encouraged and supported by the greater involvement of the Trustees of the home. Regular staff meetings and individual staff supervision appropriately minuted. Staff comments included:are held and St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 17 “We are encouraged to say what we feel. This is the best organised home I’ve worked in.” “Very good managers – good team work.” “Manager is good – looks after us as well as the residents.” “Worked in care since 1992. This is the best home I’ve worked in.” “Everybody knows what they are doing on each shift and work is rotated.” A resident commented, “The manager is very good, just right as a governor, good sense of humour.” The home does not look after any residents’ money, all are dealt with by the residents and their families. The home is a registered charity and the finances relating to the home are dealt with by the home’s trustees and the home’s administrator. A system of quality monitoring is in place. The home has achieved level 2 in P.Q.A.S.S.O, a recognised quality assurance system. The manager informed she hopes to achieve level 3, the top level, in the near future. The manager is aware of her duties under Health and Safety. All staff have received Health and Safety training. Safety certificates were seen for services and equipment, and regular checks carried out on the fire precaution equipment. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard 7 7 Good Practice Recommendations The home should improve the daily records in respect of the resident’s daily lives. The home should continue to improve its services to residents with dementia. St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Martins DS0000015469.V256278.R01.S.doc Version 5.0 Page 21 - 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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