Inspection on 09/11/05 for St Martins

This inspection was carried out on 9th November 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 21/10/09

St Martins 24/09/09

St Martins 23/08/07

St Martins 06/06/06

St Martins 22/02/06

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 Unannounced Inspection 9th November 2005 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.V264709.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 DS0000025186.V264709.R01.S.doc Version 5.0 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.V264709.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 42 Nursing Beds and 42 Personal Care Beds within an overall number of 42 beds 9th December 2004 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.V264709.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 5 hours. The inspector spoke to residents, family members and various staff. A tour was made of the home. Documentation was examined including residents’ files, staff files, policies and procedures, certificates relating to Health and Safety, and fire safety records. What the service does well: 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. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 6 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.V264709.R01.S.doc Version 5.0 Page 7 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): 2, 3, 5, 6 Residents are only admitted to the home following full assessment of their needs, this ensures the residents safety and interests are protected. EVIDENCE: Each resident is issued with a written contract which clearly states the term and conditions. A pre-admission assessment is carried out by either the Deputy Manager or suitable designated person to ensure the needs of each individual can be met. Potential residents are encouraged to visit the home prior to admission, so to ensure they have made the right choice. The home does not provide intermediate care. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 8 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, 9, 10 Staff must document daily care in reflection to the care plans created so to ensure the welfare of the residents is maintained. Care plans must be up dated to reflect a true account of the care needed, so to protect the individual. EVIDENCE: Individual care plans are created for each resident, all aspects of personal care, health and social care are included. Not all care plans written were consistent to the daily report, i.e. care plan stated liquidised diet but documented as having soft diet. Staff need to ensure all residents care plans are reviewed at least monthly to monitor care being delivered is appropriate. Risk assessments were in place where necessary. Evidence was seen of other healthcare professional advice being sort. Discussion with residents and relatives confirmed that they were included in the care planning process, annual reviews were documented in some files and evidence was seen that residents and their families were participant in the meetings. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 9 Residents stated that they felt their privacy was maintained, it was witnessed that residents received visitors in their own rooms if they wished. It was found on several drug sheets not all medication had been signed for having been given. One resident was without night sedation for 3 nights and at time of inspection the medication had not been received into the home. Controlled drugs for a resident who had left the home some time ago were found to still be in the homes CD cupboard. The staff on duty advised that they would contact the pharmacy to have them removed as soon as possible. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 10 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 Activities are planned in conjunction with residents’ wishes so to promote choice and cultural satisfaction. EVIDENCE: The home employs an activities organiser who works 10.5hrs per week. The homes activity programme is displayed on the notice board along with posters regarding visiting entertainers. The home encourages the local community into the home. Visits from local churches are arranged on a regular basis. The home adopts an open visiting policy. Residents and relatives meetings are held approximately every 3 months. The daily menu is displayed in the dining room. The chef visits the residents daily to obtain their optional choice, the kitchen will provide an alternative to the specified menu for individual residents. Menus are rotated on a four weekly basis, they are well balanced and appropriately presented. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 11 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 The home has a good complaints procedure which helps safe guard and protect residents. EVIDENCE: All residents are supported in maintaining their right to vote if they wish to do so. Those able are assisted to attend local polling stations those who are not are given the opportunity through postal vote. Where it is necessary relatives or an appointed advocate is involved to ensure residents’ rights are protected. The home has an adequate policy and procedure for POVA (Protection of Vulnerable Adults) thus ensuring residents are safe guarded from abuse, however staff present stated they had not been in receipt of any training regarding adult protection. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 12 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, 22, 24, 26 There has been some improvements to the decoration this ensures the environment remains safe and comfortable for all residents. EVIDENCE: Corridors have recently been re-decorated and evidence of on-going redecoration to residents’ rooms was noted. The home was found to be clean and free from any unpleasant odours. Most of the residents rooms were viewed, many have been personalised. Relatives are encouraged to bring in residents’ personal belongings. The communal areas are hazardous free, there is adequate number of bathrooms and all have a hoist facility. There is a courtyard off the main lounge area that residents have access to if they wish. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 13 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 The procedure for recruitment is satisfactory, this ensures all residents living in the home are safe and protected. EVIDENCE: Duty rotas were examined and it was noted that all shifts were covered with little need for agency staff. A selection of staff personnel files were examined, a robust recruitment policy was being followed, evidence that staff were being appropriately checked and screened prior to employment being offered. Residents and families who spoke with the inspector identified that they found the staff both helpful and professional. It was noted whilst touring the home that the staff had a good rapport with the residents. Staff training is continuing on a regular basis for Food Hygiene and Health and Safety. Moving and Handling training was also being delivered. Training is carried out through the Company’s internal training system. No evidence was seen that staff had training in adult protection, though a section of the induction programme covered this. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 14 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, 37, 38 The home has adequate policies and procedures in place to ensure the Health and Safety of the residents is maintained. EVIDENCE: There is currently no Home Manager. Staff who spoke with the inspector stated they felt supported by the Operations Manager who visited the home several times a week. The residents and families also stated they were happy with how the home was run. Meetings are held regularly so that opinions can be expressed. The home has an internal audit system that is monitored by the Operations Manager to ensure compliance is maintained in aspects of care planning, accidents, medication and the environment. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 15 Certificates relating to Health and Safety were examined and found to be in date. Annual service contracts were up to date. Staff received regular fire drills and these were clearly recorded. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 16 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 N/a 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 3 17 3 18 3 3 N/a 3 3 N/a 3 3 3 STAFFING Standard No Score 27 3 28 N/a 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 N/a N/a N/a 3 3 St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 17 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 OP7 Regulation 15 Requirement Timescale for action 01/12/05 2 OP9 13(2) 3 OP31 8 The Registered person shall ensure after consultation with the resident, or their representative prepare a written plan as to how the residents’ needs in respect of their health and welfare are to be met. The Registered person shall 01/12/05 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered person shall 20/01/06 appoint an individual to manage the care home 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 OP18 Good Practice Recommendations It is strongly recommended that all staff receive POVA training additional to induction training. St Martins DS0000025186.V264709.R01.S.doc Version 5.0 Page 18 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.V264709.R01.S.doc Version 5.0 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!