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Inspection on 03/06/05 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 3rd June 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 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

The home provides a pleasant domestic environment and secluded gardens. Service users feel the atmosphere is homely, quiet and routines are unhurried. The feel they are respected, receive a good standard of care and enjoy good food. The staff team is well thought of by all those spoken with.

What has improved since the last inspection?

The documentation and the care planning process has greatly improved, with a clear format providing more detailed information. Some requirements set at the previous inspection have also been addressed. The new manager shared some positive ideas she had in mind for further imporvements to the service provided within the home.

What the care home could do better:

Improvements are still required in foundation training for staff and training in Adult Protection issues. The gardens, which have great potential and provide a relaxing environment according to service users, need clearing of debris and require regular maintenance. Some areas of the home would benefit from lighter decoration.

CARE HOMES FOR OLDER PEOPLE St Martins St Martins Road Bilborough Nottingham NG8 3AR Lead Inspector Andrew Sales Unannounced 3 June 2005 10:00 rd 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 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 C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Martins Address 42 St Martins Road Bilborough Nottingham NG8 3AR 0115 929 7325 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Broadoak Group Of Care Homes Maureen Jean Hawkins CHR 21 Category(ies) of OP Old Age Both Male and Female 21 registration, with number of places St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/09/04 Brief Description of the Service: St Martins 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 C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on 3 June 2005, lasting four hours and was carried out by A.Sales, regulation inspector. The process of case tracking was used to determine outcomes for service users. This involved analysing assessment plans and discussing service users views of the care received and the environment in which they live. The inspection found that most of the National Minimum Standards that were inspected, were met or partially met. The remaining standards not assessed on this occasion will be inspected during the next unannounced inspection. The new manager arrived to introduce herself to the inspector and discussed plans for the home. The inspector found that all service users spoken with were pleased with the care they received. Staff interviewed were professional and committed. There was good availability for staff to access training and the new manager was keen to make improvements to staff training, the environment and any outstanding requirements. What the service does well: What has improved since the last inspection? The documentation and the care planning process has greatly improved, with a clear format providing more detailed information. Some requirements set at the previous inspection have also been addressed. The new manager shared some positive ideas she had in mind for further imporvements to the service provided within the home. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 6 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 C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 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 standard(s) 2,3,4,5. Service users receive an assessment prior to admission. Assessment plans are well documented. Terms and conditions for service users require completing/amending The staff team are familiar with the individual needs of the service users. The manager supports staff to access training in the needs of older people. EVIDENCE: Three care plans were checked by the inspector. They contained all the needs assessments required in this standard. They are well laid out and contain daily records and evidence of support from other healthcare professionals. Local authority assessments were present. Staff spoken with said they had received induction training and supervision and training in mandatory health andsfaeety topics as well as subjects relating to the healthcare of older people. Staff files evidenced training certificates to support this. Service users felt the staff were competent, attentive and professional. Terms and conditions issued in service users contracts are not always completed with appropriate details of fees, room number and details of the commission. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 9 St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 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 standard(s) 7,8,10. The assessment process is detailed and easy to follow for care staff. Service users are well supported. Staff understood documentation relating to service users needs and are supported in providing care. EVIDENCE: The care plans were well laid out, covered all areas of needs assessment, contained risk assessments with action plans and consent agreements where necessary. Service users commented that they were pleased with the care and support they received, which corresponds to care plans examined. Documentation contained evidence of input from other health care professionals. Accident records were observed, accidents were infrequent and well documented. Service users spoke highly of the attitude of the staff team. Staff were observed interacting and supporting service users with patience and respect. Evidence was identified of staff training and policies and procedures that relate to the promotion of independence and rights of the individual. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 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 standard(s) 12,13 Service users feel comfortable with the daily routines within the home and feel their preferences and choices are respected. EVIDENCE: Care plans demonstrated that staff obtain information on the preferences and capacities of the service user in regard to daily activities. The inspector spoke to service users who said they feel comfortable with the routines and pace within the home. Visitors are welcomed and come in regularly. There is a calendar of events that informs people of activities available. All those spoken with were happy with the choices available. Service users stated they are able to request drinks at anytime of day and night. Special diets can be catered for as described by the cook and care plans evidenced that the home refers people to the dietician for advice on nutrition. Three full meals are offered daily and snacks available at suppertime. All service users spoken with confirmed that they liked the food and could have a choice if requested. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16,18 The home has policies and procedures in place for dealing with complaints and adult protection. Staff require training in adult protection. EVIDENCE: A complaints procedure is in place. Complaints records were not inspected on this occasion. The inspector is not aware of any complaints against the service in the last year. The home has the Nottinghamshire County Councils guidance on the Protection Of Vulnerable Adults. The home also has company policies on adult protection and whistle blowing. Staff spoken with demonstrated an understanding of Adult Protection issues but had not received training. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,25,26 The location and layout of the home is suitable for its intended purpose. It was accessible to service users in wheelchairs, safe and well maintained. EVIDENCE: Rooms were individually and naturally ventilated with windows conforming to recognised standards. Central heating could be controlled in each room. Emergency lighting was fitted throughout with records of appropriate testing taking place. Room lighting was domestic with bedside lights available. Two water outlets were tested and found to be satisfactory. The home is generally clean and procedures are in place to promote hygiene. There was a malodour present in one area of the ground floor, this needs to be addressed. The garden is secluded and service users find it relaxing. It was in need of general maintenance, in particular old furniture and building materials require removal as they present a potential hazard to service users and are unsightly. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The home employs sufficient numbers of staff with an appropriate selection procedure. Staff numbers and mix of skills are relevant to the needs of the service users. Staff training is provided. EVIDENCE: A staff rota which showed which staff are on duty at any time during the day and night and in what capacity. Currently there are only 11 service users residing at the home. There are waking night staff on duty. All staff providing personal care are at least 18yrs. The manager informed the inspector that all staff are now enrolled on NVQ training. Staff spoken with confirmed that they were receiving training. Service users commented that they did not have to wait for help and did not experience any staff being too busy to asssist them when required. The files of 2 staff were examined and demonstrated that appropriate procedures were undertaken for recruiting staff that ensured the protection of service users. Police disclosure was obtained, appropriate employment history and references accessed. All staff receive terms and conditions of employment. The home has induction standards in place but training and development plans are required to meet NTO standards. The new manager confirmed this was an area she would shortly be addressing. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38 The home has appropriate measure in place to manage health and safety issues. The home records and stores information appropriately. EVIDENCE: All records were held securely and were in good order. Records were observed of Fire tests which demonstrated that the home tests the system weekly. Fire equipment, escape routes, fire doors are checked weekly by staff. The fire alarm, door releases and emergency are tested at required intervals. The direct link to the fire service was last tested on 1/10/04. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 16 A gas service inspection was conducted on 6/09/04. The passenger lift and hoists are regularly serviced. Reports were observed. The manager stated that portable appliances are tested each year. Records were not seen by the inspector. Accident records were observed and are appropriately held. Staff files contained evidence of first aid and moving and handling training. Safety procedures are posted. Service users commented that they feel their safety and well being is promoted well in the home. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x 3 3 St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? 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 2 Regulation 5 (1,a-f) Sch 4 (8) 13 (6) Requirement Timescale for action 30/08/05 2. 18 3. 19 13 (4, -c) The Registered Person shall ensure that the service users contract contains all the required information. The registered person shall make 30/08/05 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall 30/08/05 ensure that (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Ensure the gardens are free from household waste and building materials. The Registered person shall keep 4. 26 St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 19 5. 30 12 the care home free from offensive odours. Attend to the malodour present on the ground floor. The Registered Person must ensure that staff receive foundation training to NTO specification within the first 6 months of employment. 30/08/05 30/08/05 6. 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. 4. 5. Refer to Standard 8 26 35 37 37 Good Practice Recommendations The Registered Person should record separately the numbers of service users admitted to Accident and Emergency. The Registered Person should prepare a disinfection policy for the home. The Registered Person should record the numbers of service users subject to Guardianship Orders, Enduring Power of Attorney and Power of Attorney. The Registered Person should retain copies of all notification 37 forms. This will provide evidence of the numbers of deaths within the home. The Registered Person should record environmental risk assessments to comply with Health and Safety legislation. St Martins C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG8 3AR 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 C53 C03 S2217 St Martins V231906 030605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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