Inspection on 26/06/08 for St Martins

This inspection was carried out on 26th June 2008.

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

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

Other inspections for this house

St Martins 24/04/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Martins 59 Imperial Avenue Westcliff On Sea Essex SS0 8NQ Lead Inspector Jane Offord Unannounced Inspection 26th June 2008 09:50 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.V367284.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.V367284.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.V367284.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). 24th April 2007 Date of last inspection Brief Description of the Service: St. Martins is a large older style detached building situated in a pleasant residential area in Westcliff-on-Sea. The home is close to public transport, the beach, a large park and local shops. The home provides accommodation and support for up to twenty-six 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. Rooms are provided over three floors with a shaft lift connecting the floors as well as stairs between the ground and first floor. Accommodation comprises of 24 single and 1 shared bedrooms, 6 of which have en-suite facilities. The home is gradually changing the shared facilities to single rooms thus reducing the number of places available. There are two separate lounges, a large, attractive dining room, a small quiet 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. 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 £352.10 to £630.00 monthly but do not include the cost of hairdressing, chiropody, taxis, newspapers, outside visits and holidays. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is two star. This means that people who use this service experience good quality outcomes. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.50 and 16.00. The registered manager and deputy manager were both present throughout the day and assisted with the inspection process by providing documents, files and information. This report has been compiled using information available prior to the inspection, such as, the annual quality assurance assessment (AQAA) which is a self assessment document completed by the service and sent to us, as well as evidence found on the day. During the day a tour of the home was undertaken with the manager but a number of areas were revisited later. The files and care plans for three residents were inspected as well as files for three new staff members. The policy folder, the complaints log, the duty rotas and a number of maintenance records and service certificates were seen. Several staff, residents and visitors were spoken with. The medication administration round at lunchtime was followed and care practice during the day was observed. On the day the home was clean and tidy with minimal poor odour control in one or two specific areas. Residents looked comfortable and relaxed using all the communal rooms of the home. Visitors came and went and were welcomed by the staff. Individual rooms were attractively decorated with personal items such as photographs and ornaments on display. The lunch looked and smelled appetising and residents spoken with said they had enjoyed the meal. Interactions between staff and residents were friendly and staff were observed spending time sitting and talking to residents. Medication practice was safe and medicines were correctly stored. What the service does well: The service offers a good level of support to people with complex physical and cognitive needs in a homely and attractive environment. Staff are aware of the particular needs of people with a diagnosis of dementia and the environment and activities organised are reflective of the stimulation they require. The staff team is correctly recruited and undertakes regular training updates to ensure their knowledge meets the needs of the residents. They are supportive of each other covering shifts if they can so that agency staff input is limited and residents have continuity of carers. St Martins DS0000015469.V367284.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.V367284.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.V367284.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. The home has detailed information about the service offered so people interested in living there can make an informed decision. There is a robust assessment process that is undertaken and people will have confirmation that their needs can be met prior to being offered a place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive statement of purpose that was updated in November 2007. It includes details of the admission process and the complaints procedure. The service users’ guide had also been updated and was in the format of question and answer about the service and what a resident could expect living in the home. There were some colour photographs of areas of the house and garden included. Some contact details in the documents were out of date and need to be corrected to give clear information. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 9 The AQAA states that all prospective residents are supplied with a portfolio of information about the home that includes the two previously mentioned documents and in addition a selection of menus, forthcoming events planned at the home, a sample contract and a short history of the home. One visitor spoken with said, ‘we got lots of leaflets when we asked’. Each prospective resident has an assessment of need undertaken and if the home can meet their needs a letter of confirmation is sent offering the person a place and stating that their needs can be met. Three residents’ files were seen and each one contained a letter offering a place. The files all had pre-admission assessment documents that the manager said had been completed before the resident moved into the home. The documents were not signed or dated making it difficult to establish the timeframe or whether the person completing them was competent. This was discussed with the manager who agreed that signing and dating was important and would ensure it happened in the future. It was clear by comparing handwriting that the manager or the deputy manager had completed the documents seen. The assessments covered areas of physical need and looked at the resident’s preferred leisure interests. The help required with personal hygiene, mobility, continence and any special dietary needs was recorded together with a history of falls and any skin care needs. Leisure interests in one file said, ‘likes to go shopping’ and in another recorded that the resident enjoyed a pre-dinner drink. Contracts of terms and conditions of residency for the three residents tracked were seen. The resident’s next of kin or their representative had signed the contracts. This service does not offer intermediate care. St Martins DS0000015469.V367284.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 good. People who use this service will have a plan of care to help meet their needs as they would wish and be protected from harm by the medication practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files for three residents were seen and showed that an assessment of needs was carried out on admission to the home. The information collated included past medical history, any known allergies, the resident’s weight, their medication regime and their present health status. Each file had a recent photograph of the resident with signed consent to take it. The files seen all contained detailed assessments that linked to the care plans. There was evidence that assessments and care plans were evaluated and updated monthly and if the resident was unable to understand the process a family member or representative was involved and signed the review. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 11 A Waterlow score for assessment of skin integrity in each file was linked to a body map detailing any wounds, a nutrition assessment and care plan interventions for skin care and diet. Moving and handling assessments were backed up by a mobility care plan. Other care plans covered personal hygiene, dressing and undressing, continence and night needs. There was also a care plan for individual health needs so one had interventions for a resident with difficulty communicating and another had guidance as the resident became breathless on exertion. All the files seen had a monthly sensory check that covered oral care, hearing, chiropody and sight. There was a column for any action required such as, ‘needs an appointment with the optician’ or ‘six weekly check with the chiropodist due’. A record was kept of all the appointments planned with health care professionals and the treatment given. The medication policy was looked at and contained full guidance on all aspects of medication management including covert administration of medicines and the procedure for administering ‘homely’ remedies. In the residents’ files seen there were consent forms signed to authorise giving homely remedies to the person. The medication administration round at lunchtime was observed. Medication is stored in a clinic room that is kept locked and the senior carer on the shift holds the key. The home uses a monitored dosage system (MDS) that is provided by the local pharmacy so tablets are put into labelled blister packs following prescriptions to be dispensed by the staff. Medicines were given with patience, at a pace the resident could manage. Topical preparations such as eye drops or creams were given before or after the meal in the privacy of the resident’s own room. People were asked discreetly if they needed ‘as required’ pain killers. The medication administration records (MAR sheets) folder contained a list of signatures of staff authorised to give medication, for identification. Each MAR sheet had a photograph of the resident and no signature gaps were noted. If a medicine was omitted for any reason an appropriate code was used and an explanation written on the reverse of the MAR sheet under ‘carers’ notes’. The controlled drugs (CDs) register and stocks were seen. They were safely and correctly stored and the numbers tallied with the records. Staff spoken with said they had had training in medication management that was updated periodically. Records seen in personal files confirmed this. St Martins DS0000015469.V367284.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. People who use this service will have their leisure preferences taken account of and be consulted about the meals they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a carer who does nine hours a week as an activities coordinator. At the time of the inspection the manager said that due to a crisis in staffing (see staffing section) the carer, for a month, was not doing dedicated activities but using all their hours for care work. Nevertheless staff were observed sitting chatting with residents, reading newspapers and books with them. The activities programme was displayed although due to the circumstances some planned events had been cancelled. Paddington bear’s fiftieth birthday was to be celebrated with marmalade (or marmite) sandwiches and Wimbledon fortnight was to have some strawberry and cream teas. Croquet in the garden was planned if the weather was good and a musical interlude with a hired singer was on the list. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 13 The activities co-ordinator prepares a monthly report of all the events taking place in the home. There is a weekly social club for residents and families that offers refreshments and talks or art and craft activity. One report stated that a collage had been made of pasta, lentils, butter beans and pipe cleaners. To celebrate the Eurovision Song Contest all the old winning songs were sung and one day was dedicated to food and cakes from a European country for one of the residents who came from overseas. Records in residents’ files are kept of the individual pastimes they have undertaken. One recorded that the resident had participated in a lively discussion about Frank Sinatra and 1950’s fashions and on another occasion had taken a walk outside in the garden. During the admission assessment a life map is started that includes hobbies and interests, dreams and preferred outings. One resident had said they enjoyed family visits, murder mysteries on television and shopping, another one liked flower arranging, talking about plants, insects and different sports. Under dreams there was a wish for a helicopter flight and another cruise. One resident’s preferred outing was, ‘a trip into outer space’. The manager said that would be a little difficult to arrange. The residents’ spiritual beliefs were recorded and if they wished to be active the staff facilitated them attending church services. The manager said that contact was made with people attending the chosen church and they would come and collect residents to go to services. Records showed that some people had been out to church services. The home also holds a monthly nondenominational service for any resident who wishes to attend. Each file seen had contact details of the resident’s next of kin or friend with some information about their involvement. Visitors are welcome at any reasonable time and people were seen arriving during the day, welcomed by the staff and offered refreshment. The home has a small quiet lounge that is available for residents to meet visitors in private without having to take them to their bedrooms. One visitor spoken with said, ‘I like visiting here. People are always made welcome’. The chef has devised new seasonal Spring/Summer menus with input from residents through the regular meetings held at the home. The meal on the day of inspection was a choice of pork chops with baby baked potatoes, mushrooms and courgettes or an omelette with salad. The dessert was muffins and custard or strawberries and cream. The meal was served individually so residents who came later to the dining room had a fresh plate dished up. People who needed help were assisted sensitively by staff who sat with them. The meal was clearly enjoyed judging by the clean plates and residents said, ‘the food is always lovely’, ‘I get the amount I ask for’. The tea menu offers a choice of soup or a hot snack such as cheese on toast, a burger or sandwiches. A dessert of yoghurt, cake or fresh fruit was available. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 14 The kitchen was visited and the dry stores and the contents of freezers and refrigerators checked. The home holds a wide selection of ingredients and fresh fruit and vegetables. The cook said that all cakes and soups were home made and showed two cakes that had been baked that day and were cooling. All stored food was correctly labelled and dated. Temperatures of refrigerators and freezers were recorded to ensure they were functioning within safe limits for food storage. There was evidence that equipment faults are reported and dealt with speedily. The kitchen was visited by the environmental health officer a week before this inspection and although the report had not been received the manager said they had not found any concerns. Records showed that a deep clean had been done a month ago. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. People who use this service can be confident that their concerns will be taken seriously and investigated. They will have their legal rights respected and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints procedure that was displayed in the hall but is also available with the statement of purpose that is given to all residents when they first enquire about the home. The complaints log was seen but the home has not had a complaint since before the last inspection. The manager said they have an ‘open door’ policy for residents and relatives to raise any concerns and there are regular residents and trustees’ meetings held when issues can be raised. People spoken with were clear about whom to approach if they had a concern but one person said, ‘there is nothing to complain about’. The AQAA states that residents are all on the electoral roll and are assisted to vote at elections if they wish. There was evidence in the residents’ files seen that during the admission assessment their wishes with regard to voting were established and recorded. Their choice of the method of casting their vote, either in person, by proxy or a postal vote, was noted. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 16 The manager and deputy manager said they had both undertaken Safeguarding Adults training recently and there was a notice seen for a future session for staff to take place later in the month. The protection of vulnerable adults (POVA) policy was in line with the previous guidance from the Essex protection committee but needs to be updated to reflect the new referral pathway from Safeguarding Adults guidance. Staff training records showed that recognising abuse was covered during their induction and again if they undertook an NVQ qualification. Staff spoken with were clear about what they would do if they had any concerns about the safety of residents. One member of staff was asked what they would do if the registered manager gave them cause for concern and they correctly answered that they would approach the trustees. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26. Quality in this outcome area is good. People who use this service will live in comfortable surroundings that are clean and they will have personal belongings around them if they choose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a large detached building set in a quiet residential road with access to local shops and public transport. There are two large lounges that are light and airy with big windows and high ceilings. The dining room has recently been refurbished and is a very attractive room that has plenty of space for all the residents and some new storage units that are used for crockery, cutlery and activities equipment. To the rear of the house there is a conservatory that overlooks the garden. The garden has level access from the conservatory and is laid to lawn and flowerbeds. There is also a summerhouse for the residents’ use in good weather. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 18 During the day a tour of the home was undertaken with the manager. They explained the themes being introduced in the corridors to help residents identify their own rooms. One corridor has a Hollywood theme, another has a seaside theme and a third has a selection of artwork that was done by a previous resident and given to the home. Small areas within the home have been furnished for quiet seating corners, one with a fireplace and mantelshelf another with a selection of books and an old fashioned clock. On the top floor there is a reminiscence area with a collection of old items used in households and shops in days gone by. The floor covering on this floor is worn and repaired with gaffer tape. The tape is now scuffed and the area poses a trip hazard. On the ground floor is a small quiet room that can be used by residents to meet visitors in private or is used for people who wish to pray or take Holy Communion. Some residents’ bedrooms were seen and they all looked tidy and well decorated. Each had a individual colour scheme and matching soft furnishings. The rooms varied in shape and size but were all light and airy with views either over the gardens or down to the sea. Small personal items of furniture, photographs and pictures were in evidence in most rooms seen. A number of rooms have been, or are being, redecorated and looked fresh and welcoming. The laundry has recently had new equipment installed that gives better programmes for managing soiled linen. There is also an automated product feed so staff have minimal contact with potentially harmful products. Liquid soap and paper towels were in evidence throughout the home and staff were seen using protective clothing for some tasks. In one or two areas of the home a lingering odour of urine was noted. When this was discussed with the manager they said it was probably because the maintenance person who usually does the carpet shampooing had been on annual leave for the last two weeks, but they agreed the issue needed to be addressed. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. People who use this service can be confident that they will be protected by the home’s recruitment practice and that staff are trained to support them as they would wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the day there was one senior carer with three carers and at night one senior carer and one other carer. The manager and deputy manager were supernumerary but took turns to be on call at weekends. The home also employs a chef manager, a housekeeper, a cook and kitchen assistants, an administrator, domestics and a maintenance person. Staff spoken with said there were enough staff rostered to meet the needs of the residents but occasionally recently agency staff had to be used and that made the work harder as they were unfamiliar with the building and the residents. In discussion with the manager about staffing they said they had had to terminate the contracts of a number of overseas staff after their documents had been found to be forged and they were not entitled to be working in this country. A recruitment drive is underway and interviews would take place the following week to replace the staff who left. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 20 Three staff files were seen and they all contained evidence that identity documents had been seen and references had been taken up prior to appointment. A criminal records bureau (CRB) check had been done for each of them and there was evidence that for one that had an entry the circumstances had been explored. The manager said that the decision to employ the person had been made by the board of trustees after consideration. There was a copy of the contract of terms and conditions and a job description for the post applied for in the files. The induction programme records showed that all mandatory areas of training were covered including health and safety, fire awareness, medication management and care principles. Staff spoken with talked of ‘shadow’ shifts when they first started in post. Further training certificates seen showed that specialised training was accessed such as understanding dementia, Parkinson’s disease and the Mental Capacity Act. Two members of staff spoken with were able to explain how they worked to maintain the dignity of residents when supporting them with personal care. One resident said, ‘the girls are lovely, always ready to help’. A number of care staff have achieved an NVQ level 2 or level 3 qualification. Although some staff who left recently had the qualification the percentage of remaining staff with the award is 75 , which exceeds the recommendation of standard 28 of the national minimum standards (NMS). St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. People who use this service will have their views and opinions sought and acted on and can be confident that their welfare will be protected by present practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has run the home for over three years and has achieved an NVQ award at level 4 in management. Staff spoken with said the manager gives clear leadership, is approachable and friendly. During the day interactions between the manager and residents showed that people were comfortable to engage with her and she demonstrated a caring approach to issues that were discussed. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 22 The home achieved level 3 of PQASSO, which is a quality initiative package designed for use by the voluntary sector. Level 3 is the top level and now the home has set up its own audit committee to monitor and maintain the standards it has attained. There are twelve quality areas in PQASSO that all require evidence that they are met. The areas include user centred service, training and development, managing activities and monitoring and evaluation. At the last key inspection the home did not manage any personal monies for residents. A check was made with the manager that the situation remained the same and they said they still did not manage residents’ money. The home does have a supervision of staff policy but the manager said that supervision was not taking place formally. They operate an ‘open door’ policy for staff to raise any issues they wish. The manager said that the past few months had been difficult as they had been without their deputy manager but now they had returned it was an opportunity to set up a supervision programme. Staff spoken with said they felt able to approach the manager at any time but agreed that formal supervision was not happening. A number of maintenance records and service certificates were inspected and showed that the boiler had been serviced in April 2008, the gas safety certificate was issued in March 2008 and valid for a year, the lift was serviced in April 2008 and was valid for six months and the fire extinguishers were checked by external consultants in December 2007. The fire log was seen and showed that the tests for alarms, emergency lighting and fire exits had not been done for over a month when previously they had been checked weekly or fortnightly. St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 23 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 3 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 3 18 3 2 3 X X X 3 X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 2 St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? None. 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 OP26 Regulation 16 (2) (k) Requirement Provision must be made to ensure the home is free of odours to make sure it is a pleasant place for residents to live. A system of formal staff supervision must be established to ensure that staff training needs and development are in accordance with the needs of the residents. Regular checks of the fire equipment and alarms must be undertaken to protect residents. Timescale for action 26/06/08 2. OP36 18 (2) 31/08/08 3. OP38 23 (4) (c) 26/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Martins DS0000015469.V367284.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V367284.R01.S.doc Version 5.2 Page 26 - 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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