Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 11/07/06 for St Martins Care Home

Also see our care home review for St Martins Care Home for more information

This inspection was carried out on 11th July 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents spoken with indicated that they feel safe living in the home and that they are taken care of well. The gardens are well maintained and provide a comfortable place to relax, away from noise and traffic. The home is maintained in clean and hygienic manner by the domestic staff. The manager and staff continue to be very committed to providing good standards of care for the residents. Residents spoken with said they feel the staff are kind and caring and work very hard. Relatives also felt that staff work hard to provide a pleasant environment for their loved one.

What has improved since the last inspection?

Very little has changed since the last inspection.

What the care home could do better:

Three requirements remain outstanding from the last inspection. The Registered Provider continues to staff the home in such a way as to require the manager to be counted in as care hours meaning she is unable to carry out her managerial responsibilities in full. The manager must be super numery to staff care hours. The home has 20 residents and little has been done since the last inspection to improve staffing hours. The Commission received a complaint in April 2006 regarding this matter despite it initially having been dealt with in December 2005.The registered provider must ensure that staffing levels reflect the dependency levels of the residents. As a result of the manager having to carry out care hours she has been unable to carry out formal supervision with staff as was required at the last inspection. The registered provider must ensure that the manager is able to carry out her managerial role by providing enough care staff. Many areas of the home are beginning to look shabby and in need of redecoration, there is no evidence of a formal maintenance system rather an ad hoc method. The only assisted bath is not functioning properly and has not done so since January 2006, when care staff reported it. The registered provider must ensure this is mended as soon as possible, residents are being prevented from having baths where there can be fully immersed. Many of the chairs in the lounges are showing signs of wear with some having torn armrests. This does place residents with skin integrity issues at risk of skin tears. Although the home is registered for people with dementia there is no sign of the home being decorated to meet the needs of people with confusion, the corridors are dark and all the doors look the same, this can be very confusing for people with dementia. Bedrooms viewed had low light levels that may place residents with restricted vision at risk of falls. The garden area although pleasant for residents to sit in has a large quantity of what appears to be tiles, this are piled up at the side of the building and in one area next to a fence which would enable someone wishing to climb over the fence easier access to do so. There is also building rubble in one corner that must be removed as it is unsightly and places residents at risk as a trip hazard. The side gate is inadequate for it purpose as it does not keep the garden area secure and staff had wedged an old bed against it to prevent residents wandering out of the garden. This is not only unsightly but places residents at risk if they try to remove it. The hot water geezer in the kitchen has not worked for some time this has meant that staff have to boil kettles when making hot drinks for 20 residents, this is poor use of resources and the registered provider must ensure that the home is maintained in a state of repair internally and externally.

CARE HOMES FOR OLDER PEOPLE St Martins Care Home 42 St Martins Road Bilborough Nottingham NG8 3AR Lead Inspector Susan Lewis Key Unannounced Inspection 11th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Martins Care Home DS0000002217.V302499.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 Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Care Home Address 42 St Martins Road Bilborough Nottingham NG8 3AR 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) 0115 929 7325 Broadoak Group of Care Homes Mrs Barbara Elsie Nunn Mrs Gail Kirkby Care Home 21 Category(ies) of Dementia (21), Old age, not falling within any registration, with number other category (21) of places St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age, not falling within any other category (OP) (21) Dementia - over 65 years of age (DE (E) (21) Date of last inspection 20th December 2005 Brief Description of the Service: The fees are social services rates which are for 2006/07 £276-£307. St Martin’s Care Home provides 21 places for older people requiring residential care. It is situated in a quiet part of Strelley, some three miles north west of the centre of Nottingham. There are bathrooms and toilets to both floors. The home has ample communal space and extensive gardens. The home was initially registered in 1995 and subsequently in 2002 with the Commission for Social Care Inspection. The registered company is Broadoak Group of Care Homes. The Registered Provider is Mrs. B. Nunn. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection was unannounced and took place over 7 hours one Tuesday in July 2006, and was conducted by one inspector as part of the annual inspection process. A tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ records were inspected and residents, relatives and staff on duty were spoken with. What the service does well: What has improved since the last inspection? What they could do better: Three requirements remain outstanding from the last inspection. The Registered Provider continues to staff the home in such a way as to require the manager to be counted in as care hours meaning she is unable to carry out her managerial responsibilities in full. The manager must be super numery to staff care hours. The home has 20 residents and little has been done since the last inspection to improve staffing hours. The Commission received a complaint in April 2006 regarding this matter despite it initially having been dealt with in December 2005. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 6 The registered provider must ensure that staffing levels reflect the dependency levels of the residents. As a result of the manager having to carry out care hours she has been unable to carry out formal supervision with staff as was required at the last inspection. The registered provider must ensure that the manager is able to carry out her managerial role by providing enough care staff. Many areas of the home are beginning to look shabby and in need of redecoration, there is no evidence of a formal maintenance system rather an ad hoc method. The only assisted bath is not functioning properly and has not done so since January 2006, when care staff reported it. The registered provider must ensure this is mended as soon as possible, residents are being prevented from having baths where there can be fully immersed. Many of the chairs in the lounges are showing signs of wear with some having torn armrests. This does place residents with skin integrity issues at risk of skin tears. Although the home is registered for people with dementia there is no sign of the home being decorated to meet the needs of people with confusion, the corridors are dark and all the doors look the same, this can be very confusing for people with dementia. Bedrooms viewed had low light levels that may place residents with restricted vision at risk of falls. The garden area although pleasant for residents to sit in has a large quantity of what appears to be tiles, this are piled up at the side of the building and in one area next to a fence which would enable someone wishing to climb over the fence easier access to do so. There is also building rubble in one corner that must be removed as it is unsightly and places residents at risk as a trip hazard. The side gate is inadequate for it purpose as it does not keep the garden area secure and staff had wedged an old bed against it to prevent residents wandering out of the garden. This is not only unsightly but places residents at risk if they try to remove it. The hot water geezer in the kitchen has not worked for some time this has meant that staff have to boil kettles when making hot drinks for 20 residents, this is poor use of resources and the registered provider must ensure that the home is maintained in a state of repair internally and externally. 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 Care Home DS0000002217.V302499.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 Care Home DS0000002217.V302499.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): 3 and 6 The quality in this outcome area is good. Residents do not move into the home without having their needs assessed and being assured that these will be met. EVIDENCE: This service does not provide intermediate care. Three care plans were assessed as part of the inspection. These are the standard Broadoak company assessments. They provide sufficient detail and contained all the needs assessments required to meet this standard. They are well laid out and contain daily records and provide evidence that healthcare professionals are contacted to provide appropriate healthcare as required by the residents. There was evidence that Local authority assessments were obtained prior to residents being admitted to the home. The manager also confirmed that she assesses residents in hospital prior to them moving into the home. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 9 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 and 10 The quality in this outcome area is good. Residents have their personal and health care needs set out in individual plans, although health care needs are met they are compromised by limited information on risk assessments. Residents are protected by the homes policies and procedures for dealing with medicines. Residents feel they are treated with respect and their rights to privacy are upheld. EVIDENCE: Three care plans were viewed and showed that care was set out in detail, although information regarding how care should be delivered could be detail more accurately what staff actually do when providing care. Evidence was seen that risk assessments are carried in all key areas, including falls, pressure care, continence and nutrition. However in some risk assessments viewed they did not clearly describe what action was needed to minimise the risk. The Registered Person must ensure that risk assessment detail the action needed to minimise the risk to the residents. Residents spoken with said that they were happy with the care they received and felt that the care staff were kind and gave as much support as they St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 10 needed. Staff respected their dignity and only entered their bedrooms when after knocking. Staff were observed ensuring residents were clean and tidy throughout the day. Staff spoke with respect to residents and showed affection when addressing residents. Relatives spoken with spoke highly of staff’s hard work and commitment to their work as well as how kind they were. Evidence was seen that staff have received a variety of training on medication administration. The medication is stored securely and appropriately, The Boots’ Monitored Dosage System is used and the medication administration sheets were accurate, there appeared to be a discrepancy with one resident’s medication and the registered manager must ensure that medication is regularly audited to prevent errors of this nature. The controlled drugs were stored correctly and records were all signed correctly. Staff spoken with had a good understanding of medication procedures, residents were all risk assessed as to whether they were able to self medicate or whether it was more appropriate for the staff to administer medication. The registered manager had a good understanding of what constituted covert medication and was therefore able to protect residents from inappropriate medication. Information regarding the procedure in the event of drug error is available to ensure staff know what action to take to protect residents. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 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, 13, 14 and 15 The quality in this outcome area is good. Residents find the lifestyle within the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests. Residents are able to maintain contact with their family and friends and are able to exercise control over their lives. Residents receive a wholesome balanced diet at times convenient to them. EVIDENCE: Although there are no organised activities as such, residents said that they were able to spend the day, as they wanted, on the day of the inspection residents were seen listening to the radio or playing dominoes. Residents and relatives spoken with said that they have an entertainer come in regularly who sings to them and they recently had a barbeque and a trip to Twycross Zoo. It is strongly recommended that the registered manager investigate suitable activities for residents with dementia to ensure that they are provided with appropriate stimulation. Residents spoken with said that their relatives were welcomed to visit the home whenever they wanted to and relatives were seen coming and going throughout the day. Relatives also confirmed that they could see their loved ones whenever they wanted and were offered refreshments when they came. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 12 Residents spoken with said they could not remember if they had a care plan or had ever seen one. The manager and staff said that when they reviewed plans they usually sat with the resident with the care plan and discussed it with them. Residents were seen being provided with drinks throughout the day and residents said that they liked the meals. Evidence was seen that home made cakes were made for their tea time and that their lunch was also home made. Relatives spoken with said that that from what they had seen they thought the meals looked very good. The kitchen was clean and well ordered, however there was no soap in the dispenser by the hand washbasin, also the water heater to make hot drinks with was broken and appeared to have been broken for some time. This meant that staff had to boil kettles to make the hot drinks for 20 residents throughout the day. It is strongly recommended that the registered provider have this mended. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 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 and 18 The quality in this outcome area is good. Residents and their family are confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: The Commission has received one complaint regarding staffing in April 2006, as this is an on going requirement this will be dealt with under staffing standards. The home has not received any complaints since the last inspection. However the Commission does not have concerns regarding the registered manager’s ability to handle complaints. All residents spoken with said that they would know who to complain to and felt confident that it would be dealt with. Relatives also felt that any concerns that they had raised would be dealt with. Staff spoken with had not received training regarding adult abuse but did understand what it was and what they should do. Residents’ monies are stored in a safe and records show they are protected from financial abuse. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 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, 25 and 26 The quality in this outcome area is poor. Residents do not live in safe wellmaintained environment, there are insufficient and suitable washing facilities, and residents’ surroundings do not always meet their needs. However the home is clean and hygienic. EVIDENCE: Although there is evidence that the some parts of the home have recently been repainted, such as the external windows and the corridors evidence showed that equipment is poorly maintained. The only assisted bath in the home, a Parker bath, has been broken since January 2006 and has been reported to the head office of Broadoak Care but it remains broken. This means that residents cannot be fully reclined in the bath and can only have a bath in an upright position with staff pouring jugs of water over residents to try to ensure residents are clean. This is unacceptable as it compromises staff’s ability to maintain residents hygiene and skin integrity. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 15 The registered provider must ensure this bath is repaired. The other bathroom is unsuitable to use for assisting residents with bathing. Apart from a book that shows when maintenance issues have been reported there is no clear evidence of a programme of routine maintenance. A number of chairs were noted in the lounges to be very worn and in one case the armrest was ripped placing residents at risk of skin tears. The corridors are dark and the lighting in the bedrooms viewed is also poor. The home is registered for dementia yet the corridors do not differentiate what doors are for and they are all painted the same colour, which could cause confusion for residents with dementia. There is no evidence that that the premises are suitable for the purpose of achieving the aims and objectives of its registration. The home is clean and domestic staff were seen throughout the day cleaning various areas of the home. The washing is done in the central laundry and the equipment met standards, residents said that they were happy with the standard of cleanliness in their rooms and of their laundry. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 16 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 and 30 The quality in this outcome area is poor. Residents are not guaranteed that their needs will be met by the number of staff on duty, however staff are competent and receive some training. Poor recruitment practice places residents at risk. EVIDENCE: An immediate requirement was set at the last inspection regarding staffing hours. This appears to have been met briefly over the Christmas period, but those staff who were taken on have left. A staff rota was seen, which showed who was on duty at any time during the day and night and in what capacity. It was evident that the manager was still being used to cover care hours. There are now 20 residents, 15 of which are classed as high dependency through payments from Social Services. The manager reported that 6 residents had dementia with another 4 who could be classed as having the onset of dementia, 4 residents with limited mobility required two staff to assist with transfers, 2 residents need assistance at mealtimes, and 1 resident has pressure care needs. If the manager was super numery as she should be this would mean the care would be performed the majority of the time by two staff. This is incompatible with the needs of the residents and the size and layout of the building. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 17 Evidence was seen that five members of staff have recently enrolled on NVQ level 2 training and this will ensure with the existing staff who already have NVQ level 2 or above that residents will be in safe hands at all times. Recruitment files were looked at, and the quality of information varied considerably, under the new registered manager staff recruited had their Criminal Records Bureau checks carried out, however there was no evidence that PoVA first checks were being carried out whilst waiting for the Criminal Records Bureau check to be returned. The manager reported that head office deal with this. It is strongly recommended that head office let the home know that the PoVA First check has been received. Not all files had two written references and the Registered Person must ensure that appropriate recruitment checks are carried out on all staff before they are employed. Staff are given copies of the General Social Care Council code of conduct and practice are given to staff to ensure they are aware of what standards they must work to. Staff receive some mandatory training but not all staff had up to date Food Hygiene training, all staff who handle food, not just the kitchen staff must have basic food hygiene training to ensure that residents are not placed at risk by poor hygiene practice. There was little evidence that staff had received an induction within six weeks of employment and staff spoken with said that they had been shown round the building and given information about Fire Safety. The Registered Person must ensure that staff receive appropriate induction training within six weeks of their appointment. Evidence was seen that staff had accessed a number of role specific training courses, including Challenging Behaviour and Dementia Awareness training. The manager had also enrolled staff on Safe Handling of Medication as well as the Boots training for care staff who administer medication. This is seen as good practice. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 18 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, 35, 36 and 38 The quality in this outcome area is poor. Although is generally well managed and staff and the manager put the needs of the residents first, the operational management and development of the home continues to be undermined by the current working schedules of the manager. Staff do not receive formal supervision although have their practice supervised. Residents and staff’s health, safety and welfare are promoted and protected, however lack of support by Broadoak head office compromises this. EVIDENCE: The manager is NVQ 4 qualified and is also an NVQ assessor. She has been registered with the Commission as a fit person to manage a care home. However her ability to manage the home is compromised by having to carry out care tasks, which take her away from managing the home. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 19 This matter has also been addressed under the standards on staffing. An Immediate Requirement was set at the last inspection to ensure that the manager’s hours were super numery; this has not been met. Residents, staff and relatives spoken with were very positive about the manager. All those spoken with said that she was supportive and helpful. Although residents’ files showed that there was a quality questionnaire carried out, they were not dated and nothing was done with them and so were not effecting the home’s development plan. It is strongly recommended that returned information from the quality assurance questionnaires are made available for current and prospective residents in a revised Statement of Purpose and Service User Guide. The Commission has not received any Regulation 26 forms regarding this home, these reports are important to show that the provider is aware of what is happening in his home, and if the Commission does not receive them this reflects on the fitness of the provider. Residents’ money is stored in a safe and receipts are kept, however in the monies checked they did not always tally and in two cases only one person had signed for the money. The registered manager must ensure that residents’ money is monitored more closely to minimise mistakes. Residents care plans viewed showed who was involved in looking after residents money and if someone had Power Of Attorney. A requirement was made at the last inspection for the manager to carry out formal supervision with staff this is not taking place. The manager confirms that as she works alongside staff she supervises their performance. However staff are not receiving the formal supervision as sated in standard 36. This looks at not just practice, but how their work impacts on the philosophy of the home and their career development. It is not being met as the manager is being used as a carer and this impacts on her time to carry out management tasks. Evidence was seen that water temperatures were being taken routinely to minimise the risk of residents getting scalded, however the water tests to prevent the risk of Legionella were not being carried out according to Broadoak’s procedures. It appeared from evidence seen that these tests are not carried out internally by staff in the home but someone from head office. This was not being done. The Registered Provider must ensure that appropriate measures are taken to ensure residents are not placed at risk. A requirement was set at the last inspection regarding evidencing the maintenance of equipment within the home. Evidence was seen that appropriate maintenance is carried out on the hoist, lift, gas boiler and fire equipment. St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 20 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X 2 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 X 2 1 X 2 St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 21 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 OP8 Regulation 13(4)(c) Requirement The Registered Person must ensure that unnecessary risks to health and safety of service users are identified and so far as possible eliminated. The Registered Person must ensure that the premises are suitable for the purpose of achieving the aims and objectives set out in the statement of purpose. Appropriate efforts must be made to ensure residents with dementia have suitable accommodation. The Registered Person must ensure that equipment provided at the care home for the use by service users or persons who work at the care home is maintained in good working order. The Parker bath must be repaired. The Registered Person must ensure that lighting is suitable for service users. Lighting in residents’ accommodation must meet recognised standards. Timescale for action 01/09/06 2 OP19 23 (1)(a) 01/10/06 3 OP21 23 (2)(c) 01/09/06 4 OP25 23 (2)(p) 01/10/06 St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 22 5 OP27 12(1)(a) 13(4)(c) 18(1)(a) 6 OP29 19 (1)(b) Sch 2 7 OP30 18 (1)(c)(i) 8 OP32 10(1) 12(1)(a) (b). 9 OP33 26 (1-5) 10 OP36 18 (2) The Registered Person must ensure adequate numbers of staff are on duty 24 hours per day. (Outstanding requirement unmet 20/12/05) The Registered Person shall not employ a person to work at the care home unless has obtained in respect of that person the information and documents specified in paragraphs 1 to 6 of Schedule 2. The Registered Person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. Staff who handle food must have food hygiene training. The Registered Person must ensure sufficient super numery management hours are available to ensure effective management of the home. (Outstanding requirement unmet 20/12/05) The Registered Person must ensure that visits according to regulation 26 are carried out regularly. The Registered Person must ensure staff are appropriately supervised. (Outstanding requirement unmet 30/01/06). 01/08/06 01/08/06 01/09/06 01/08/06 01/08/06 01/08/06 St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 23 11 OP38 13 (4)(c) The Registered Person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Procedures for eliminating the risk of Legionella must be followed. 01/08/06 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 2 3 Refer to Standard OP12 OP15 OP33 Good Practice Recommendations The registered manager investigates suitable activities for residents with dementia to ensure that they are provided with appropriate stimulation. The registered provider has the hot water heater in the kitchen mended to enable staff to make hot drinks more efficiently for residents. The registered provider uses the returned information from the quality assurance questionnaires and makes it available for current and prospective residents in a revised Statement of Purpose and Service User Guide. The registered person should make arrangements to minimise the risk of residents’ money not adding up. 4 OP35 St Martins Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000002217.V302499.R01.S.doc Version 5.2 Page 25 - 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!