Inspection on 06/06/06 for St Martins

This inspection was carried out on 6th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Martins 21/10/09

St Martins 24/09/09

St Martins 23/08/07

St Martins 22/02/06

St Martins 09/11/05

St Martins 09/12/04

St Martins 13/07/04

St Martins 18/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Martins Oakhill Park Liverpool Merseyside L13 4BP Lead Inspector Andrea Morris Key Unannounced Inspection 6th June 2006 09:00 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 DS0000025186.V292631.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Address Oakhill Park Liverpool Merseyside L13 4BP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 228 0983 Southern Cross Care Management Limited Jean Marjorie Redfern Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 42 Nursing Beds and 42 Personal Care Beds within an overall number of 42 beds 9th November 2005 Date of last inspection Brief Description of the Service: St Martins Care Centre is a care home that provides personal and nursing care for 42 older people. The home is situated in the Broadgreen area of Liverpool and is within easy access to bus routes, churches, shops and local amenities. The home is a purpose built single storey building. There is a car park to the front of the home; a garden is at the rear of the premises and an enclosed courtyard area for residents to sit. All bedrooms provide single accommodation and have 20 en-suites facilities. Communal space within the home consists of three lounge areas and a large dining room. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took five and a half hours to complete. During the inspection a tour was made of the home. The inspector spoke to staff, residents and the manager. Some visitors also spoke to the inspector during the visit. A variety of documentation was examined including resident care files, staff personnel files, certificates relating to Health and Safety were inspected including Fire records. Staff training records were also viewed. The pharmacy inspector for the Commission for Social Care Inspection also visited the home to conduct a full inspection of medication. What the service does well: What has improved since the last inspection? What they could do better: Although there has been some recent improvement to staff personnel files there is still evidence lacking to support the application is appropriate. The St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 6 inspector was shown a copy of the administration action plan to identify these areas that require addressing.’ Care files have recently been updated and evaluated this must continue on an at least monthly basis to ensure all care is relevant. The pharmacy inspector completed a full medication inspection and all requirements made have been included within this report. 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 DS0000025186.V292631.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 DS0000025186.V292631.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Residents are only admitted following a full assessment of their needs by a suitably qualified person. This contributes to the residents’ safety. EVIDENCE: The home has a satisfactory statement of purpose and Service user guide that has been amended to include the details of the new manager. It contains suitable information to assist potential residents and their families to make relevant choices. Each resident admitted to the home is issued with a contract, which clearly defines the terms and conditions of residency. The manager or other suitable qualified person completes a pre-admission assessment prior to any person being offered a place in the home. This practice promotes safety for all residents. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 9 Any potential resident and their relatives/friends can visit the home, if preferred they are able to stay for a few hours or a meal. All residents living in the home are registered with a GP, all professional visitors visits are recorded this includes Social Workers, Chiropodist, District Nurse etc. The home is not registered to provide intermediate care. St Martins DS0000025186.V292631.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, 11 Residents are able to make choices, this promotes independence and helps ensure respect is given to residents. EVIDENCE: Each resident has their own care file where care plans and relevant risk assessments are formulated. Since the last inspection there has been some improvement to care files to ensure that regular evaluations of care plans and risk assessment are being completed. The home manager is currently auditing care files each week to monitor that good standards of care are being maintained. This practice must continue in order for residents’ safety to be maintained at all times. All residents who spoke to the inspector stated they were happy with the care they received. Some residents also commented that they were happy with the appointment of the new manager. Residents discussed with the inspector that the staff respected any decisions they made. Residents confirmed they could choose how and where to spend St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 11 their day, they also stated staff were polite and professional at all times. lady also stated that staff would try to go the extra mile if asked. On the day of the inspection several visitors identified that they were also happy with the home and care their loved ones received. The visitors confirmed that staff were friendly and helpful. One The home has an adequate policy in relation to care of the dying resident. The home will try to accommodate residents’ and relative’s wishes ensuring the appropriate care can be given within the home. The pharmacy inspector completed a full inspection in relation to all medication and requirements identified have been included within this report. St Martins DS0000025186.V292631.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Meals are well balanced and nutritious thus assisting in maintaining residents nutritional well-being. EVIDENCE: The kitchen is well organised and found to be cleaned to a good standard. Residents are offered a choice at each mealtime. Residents stated they enjoyed the meals and also confirmed at times they could make alternative choices which were catered for. The kitchen maintains adequate stock levels and all stock was found to be in date. All fridge temperatures are recorded on daily basis. The home employs an activity organiser for 10 hours per week. Since the last inspection there has been some further development in the provision of activities. There is a weekly activity plan displayed in the entrance area, evidence was seen that visiting entertainers are provided on a regular basis. There is still a need for more 1-1 activities to be provided allowing all residents to lead a fulfilling lifestyle. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 13 Residents stated they were able to choose if they wanted to participate in activities. Some residents stated they never chose to participate and staff respected their decision. The Roman Catholic Church and the Church of England visit the home at least monthly; communion is delivered to those residents who request it. The home operates an open visiting policy, relatives who spoke with the inspector confirmed they could visit any time, and staff always welcomed them. Relatives and residents also stated staff respected their wishes of privacy during visiting times. A resident/relatives meeting was recently held, with the manager and activities person were present. This gave the residents an opportunity to raise any issues they had. Residents also said they felt their needs were being met, they felt they had confidence in the staff and manager to care for them adequately. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Staff receive training in Adult protection, thus promoting the safety and well being of residents. EVIDENCE: The home has an adequate complaints procedure, which clearly details how to make a complaint, and names and addresses both of Head Office and the Commission for Social Care Inspection. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. Complaints are recorded in the complaints file held in the home, however not all complaints made verbally have been recorded; this must be done to demonstrate what action has been taken. On entering the home all residents are registered on the Electoral Role, residents are able to retain their right to vote through either the postal voting option, or if they prefer they can attend the local polling station. The home displays in the entrance area an independent advocacy agency which residents or their families are able to contact confidentially. There has been a great improvement around training of staff in adult protection. Since the last inspection the majority of staff including ancillary staff have been trained in Adult Protection and Whistle blowing. Adult protection training is discussed with all new staff members during the induction period. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 15 The home’s policy on Adult protection remains adequate. The home also has a copy of the Liverpool Adult Protection Policy. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25, 26 Residents’ rooms are personalised, creating a homely atmosphere and promoting a sense of belonging. EVIDENCE: Since the last inspection the re-decoration programme of the communal areas has been completed. All bedrooms are re-decorated as needed and all seen were found to be well maintained. The home is situated on one level and there are wide spacious corridors that enable wheelchair access. The home has suitable numbers of ramps so residents are able to access the grounds and grab rails are in all corridors. There are sufficient numbers of bathrooms, which offer assisted facilities. Water temperatures are recorded on a weekly basis, and on checking were within the safe limits. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 17 The home has the use of a Stand aid and a Oxford hoist, which are regularly serviced. Residents have their own room; the home encourages residents to bring in small items of personal effects to assist them in settling into the home and to create a homely atmosphere. The home is maintained to a good standard, it was noted to be clean and tidy in all areas. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 18 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, 28, 29, 30 Staff need to continue with regular training to ensure the safety of residents is maintained. EVIDENCE: A sample of staff rotas were seen and it was noted the staffing levels were constant with no shortages identified. The home does not use regular agency staff, as there are sufficient staff to maintain the staffing levels required. Only 25 of care staff hold a certificate in NVQ2 care. There are currently a further 6 staff who have registered for the NVQ programme and are waiting to commence the coursework. A selection of staff personnel files were examined, it was identified that although some improvement has been made since the last inspection there is still evidence missing. Not all files contained evidence to support the staff member had been CRB (Criminal Records Bureau) checked, this must be addressed to ensure residents’ safety is maintained. Staffs training records have been up dated since the last inspection. Some staff have not received training in mandatory subjects, on the day of the inspection staff where being trained in Moving and Handling skills. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 19 Both the manager and training manager at the home provides training. There are plans to access further training from specialist nurses such as diabetic nurses and other healthcare professionals. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 20 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, 32, 33, 34, 35, 36, 37, 38 Staff receive leadership and guidance from the newly appointed manager, which assists in promoting good standards of practice. EVIDENCE: A manager has been appointed in April 2006. An application to register is required by the Commission for Social Care Inspection. Residents who spoke with the inspector stated they felt the manager was pleasant and they had got to know her and felt they could discuss any issues with her. Staff stated that they found the manager to be approachable and friendly. They liked her ‘hands on’ approach. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 21 The company regularly reviews all its policies and procedures to ensure care remains appropriate. Health and Safety records were examined and all found to be fully recorded. Certificates relating to all aspects of the home were in date and filed systematically. The maintenance man checks the fire system on a weekly basis. Evidence was seen that staff receive regular fire drills promoting safe practice in the home. There is a new administrator to the home. Finance records were seen and all those seen were found to be correct. Records of all finances are maintained and an audit trail can be made from the records kept. Staff receive regular supervision, to ensure care practices are maintained to an adequate standard. Records of all supervision are kept in good order. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 22 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 3 St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation Requirement Timescale for action 30/06/06 15(2)(b)(c The registered person shall keep ) the service users plan under review and revise the plan as necessary. 13(2) The registered person must ensure that medication policies and procedures be reviewed in line with Royal Pharmaceutical Society of Great Britain and Nursing & Midwifery Council guidelines to cover all aspects of medicines management. The registered person must ensure that full and accurate records are kept of all medicines received, administered and leaving the care of the home. There must be a full record of all medication currently prescribed for each resident. The registered person must ensure that all medication is only administered in accordance with the General Practitioners instructions. Sufficient supplies of medication must be available DS0000025186.V292631.R01.S.doc 2. OP9 31/07/06 3. OP9 13(2) Sch 3 (i) 30/06/06 4. OP9 13(2) 07/06/06 St Martins Version 5.2 Page 24 for all residents at all times. 5. OP9 13(2) The registered person must ensure that medicines are only administered to the resident for whom they were prescribed. There must be no sharing of tablets, creams or other preparations. The registered person must ensure that all Controlled Drugs destroyed in accordance with current legislation The registered person must ensure that nurses take and record the residents pulse prior to the administration of Digoxin. The registered person shall ensure that persons employed to work in the care home receive training appropriate to the work they perform. The registered person shall not employ a person to work in the care home unless he/she has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 in schedule 2 07/06/06 6. OP9 13(2) Sch 3 (i) 07/06/06 7. OP9 13(2) 13(6) 30/06/06 8. OP28 18(c)(i) 31/08/06 9. OP29 19(1)(b) 30/06/06 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 Criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all service users prescribed such items. DS0000025186.V292631.R01.S.doc Version 5.2 Page 25 St Martins Verbal dose changes and new medication should be accurately entered onto Medication Administration Record charts with staff signature, date and authority where appropriate. Verbal dose changes should be confirmed in writing by the prescriber A second member of staff should witness/countersign all hand written entries on Medication Administration Record charts The opening date should be recorded on eye drops and other items with a short shelf-life Appropriate warning signs should be displayed on the doors to all areas where oxygen is stored or used. Medication trolleys should be secured to the wall when not in use Written authorisation should be obtained from the prescriber whenever medication is administered outside the product licence e.g. via PEG tubes. 2. OP12 It is strongly recommended that 1-1 activities be included within the regular activity programme to enable all residents the opportunity to participate 3. OP16 It is strongly recommended that all concerns are recorded along with the action taken to ensure evidence is retained for inspection. St Martins DS0000025186.V292631.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 DS0000025186.V292631.R01.S.doc Version 5.2 Page 27 - 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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