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Inspection on 04/03/08 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 4th March 2008.

CSCI found this care home to be providing an Adequate service.

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.

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

A warm and welcoming atmosphere was evident on entering the home and staff were observed to interact in a positive and meaningful manner with both people using the service and their relatives. All people using the service spoke positively about the care received offering comments such as, I am warm and comfortable, the food is good, what more can I ask for,` we are very well looked after, it is a good establishment, I could talk with the staff if we were unhappy but we have no need to complain,` `I can go out when I please, the staff are very nice and here when I need them,` and `we are both happy here and well looked after.` One relative spoken with also offered positive comments about the service and the staff. People using the service are enabled to maintain contacts with relevant others and visitors are always made welcome when they come to the home. Should one wish to partake in activites anumber of these are available for people to join in. Food delivered is at a good standard and choices are available at each meal.

What has improved since the last inspection?

Information gained in the preadmission assessment is now fully utilised in the plan of care, thus ensuring that the needs of people using the service are fully met. Improvements have taken place in regard to medication administration and recording to ensure that people using the service are protected. Although bedroom furniture has not been replaced, the offending parts that may cause risk to people using the service have been removed to ensure that people are protected. The pathway in the garden has now been made safe, allowing people better access to the garden.

What the care home could do better:

Issues of people sitting in a smoking area when they do not smoke need to be explored and documented to ensure that they consent to this and their rights are not infringed upon. Further development of risk assessments in regard to the safe use of bedrails and people smoking in the home are required to ensure that all people using the service are fully protected. Handwritten entries on medication charts must be signed by two members of staff to show that these have been checked as correct to avoid any potential errors in administration. The complaints policy needs updating to accurately reflect the details of the Commission for Social Care Inspection, this must also be made available to people using the service or their relatives if requested to ensure that they are fully informed of how to make a complaint should they need to. Some bedroom furniture now needs replacing to ensure that people have well maintained and fully functioning furniture available for their use. Evidence to show that staff have achieved training in all compulsory areas is needed to demonstrate that all staff have the necessary skills and knowledge to meet the needs of people using the service. Further development of the quality assurance systems are needed to ensure that the service is monitored and views of the people living in the home are fully considered.

CARE HOMES FOR OLDER PEOPLE St Martins Care Home 42 St Martins Road Bilborough Nottingham NG8 3AR Lead Inspector Karmon Hawley Unannounced Inspection 4th March 2008 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.V359887.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.V359887.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 *** Vacant *** Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age, not falling within any other categort (OP) (21) Dementia - over 65 years of age (DE(E) (21) Date of last inspection 10th July 2007 Brief Description of the Service: St Martin’s Care Home provides 21 places for older people requiring residential care who also have a diagnosis of dementia. 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. 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. There is an assisted bath on the ground floor to support residents in bathing. Suitable aids and adaptations are obtained through the district nursing service. The home has ample communal space and a pleasant enclosed garden. The fees are social services rates, which are for 2007/08 £307. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. We reviewed all of the information we have received about the home since we last visited and we considered this in planning the visit and deciding what areas to look at. We did this inspection with one inspector; it was unannounced and took place over one day. The main method of inspection we use is called ‘case tracking’ which involves us choosing three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. We spoke to two members of staff, five residents and one relative to form an opinion about the quality of the service being provided to people living at the home. We read documents as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. What the service does well: A warm and welcoming atmosphere was evident on entering the home and staff were observed to interact in a positive and meaningful manner with both people using the service and their relatives. All people using the service spoke positively about the care received offering comments such as, I am warm and comfortable, the food is good, what more can I ask for,’ we are very well looked after, it is a good establishment, I could talk with the staff if we were unhappy but we have no need to complain,’ ‘I can go out when I please, the staff are very nice and here when I need them,’ and ‘we are both happy here and well looked after.’ One relative spoken with also offered positive comments about the service and the staff. People using the service are enabled to maintain contacts with relevant others and visitors are always made welcome when they come to the home. Should one wish to partake in activites a St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 6 number of these are available for people to join in. Food delivered is at a good standard and choices are available at each meal. 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 St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 8 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.V359887.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are assured that their needs will be assessed and that staff can meet these before they may a decision to move into the home. The service does not offer intermediate care. EVIDENCE: Before admission to the home, the acting manager visits prospective people who may wish to use the service in the community, to carry out a preadmission assessment to ensure that the staff are able to meet their needs. There was evidence of these assessments taking place within those case files observed. One member of staff spoken with was able to discuss the preadmission process that takes place before any one is admitted to the home and they said that they were always informed of peoples needs before they moved in. One relative spoken with stated that their family had initially entered the home on respite care but have decided to stay as they are very happy. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 10 The service does not offer intermediate care. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although plans of care are at a good standard, additional work is required in regard to recording people’s preferences about the smoking arrangements to ensure that their rights are not infringed upon and also risk assessment documentation to ensure that people are fully protected. Although improvement has been made on medication management further work is needed to ensure that service users are fully protected. EVIDENCE: Plans of care reflected people’s choices and preferences and outlined their strengths as well as the assistance that they required to ensure that independence is maintained. Work has taken place on ensuring an increased number of risk assessments have been put into place to ensure that people using the service remain safe, however in regard to entrapment and the use of bedrails further work needed was discussed with the acting manager as these did not fully cover the checks required. This was further discussed with staff who were able to discuss the basic principles of the checks needed to ensure the safe use of bedrails. People using the home are able to smoke in a designated area, the safety checks that take place and the consent of other St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 12 people using this area were discussed with the manager, however there was no written documentation available to substantiate that risk assessments had taken place and other people were happy with this arrangement. On speaking with one person who uses this area to sit in, when asked about the smoking arrangements, they stated that they did not mind that people smoked near to them. Staff spoken with were fully able to discuss the individual care that each person required and how they supported them in meeting their needs. Several positive comments were received from people using the service; ‘we are happy here and well looked after,’ we are very well looked after it is a very good establishment,’ ‘ I am very satisfied with the way we are cared for in everyway and very mush appreciate the staffs personal attitude towards us,’ and ‘I am well cared for, I am warm and comfortable, what more can I ask for.’ To ensure that people’s health needs are met access to services such as the general practitioner, district nurse and dentist are accessed as required. There was evidence within people’s case files to show that visits had taken place. A communication book has also been introduced so that each staff member is aware of any doctor’s visits that are booked or need to be booked to ensure consistency of care. The acting manager stated that the district nurse supplies all the necessary equipment needed to maintain healthy skin. There was evidence of relevant equipment being available when touring the home. One person using the service spoken with said that they could see the doctor if they were unwell and also discussed how the nurse visits them to do their dressings on their legs. Staff spoken with were able to discuss the emergency procedures in regard to contacting the doctor or the ambulance services to ensure that people are safe at all times. The medication practices and procedures were observed to ensure that people receive prescribed medication appropriately. The medication records corresponded with the prescription and there were no gaps in signing for medication administered. Handwritten entries on the medication record had not been signed by two people to show that these had been checked as correct. All variable doses were clearly identified on the medication record and medication had been dated when opened to ensure that only in date medication is administered. Fridge temperatures were recorded to ensure that medication is stored at the correct temperature, however room temperatures had not been recorded. The lunchtime medication round was observed and the acting manager followed good practice. Staff spoken with were able to discuss how they ensure that people’s privacy and dignity is maintained, they stated that they make sure that they knock on doors before they enter rooms and also that doors are closed when assisting people in their care. Shared rooms have screening in place to ensure that privacy is maintained. Should the district nurse visit people, care and treatment is always carried out in their own room, and one person spoken with St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 13 was able to confirm that this takes place. Staff were observed to treat people in a dignified manner and maintain their privacy when attending to their needs. Two people using the service spoken with said, ‘staff are very nice and caring, they always make sure that they ask me what I want before they do anything,’ and ‘ staff usually knock on my door before they come in to see me.’ St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are enabled to live an enjoyable life and partake in activites should they choose. People using the service are enabled to maintain relations and contacts with people that are important to them. EVIDENCE: Although there is no specific member of staff that delivers activites to people using the service, all members of staff assist in this throughout the day. Activites such as scrabble, games, pool and seasonal parties are offered and outside entertainers such as Mr Motivator (music to movement) visit the home. On the day of the visit, six people were observed to join in one of these sessions. Three people spoken with offered the following comments; ‘I enjoy playing pool, I often play with the staff,’ ‘there are quite a few things to do, but I mainly enjoy occupying myself,’ and ‘there are activites to join in, I enjoy them and tend to take part in most of them.’ To ensure that people who use the service remain in touch with people that are important to them there are no restrictions on visiting and visitors may be received in private should they wish. One visitor was spoken with who spoke very positively about the care that their relative received and the staff and St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 15 home in general, they stated that they were always made welcome when they visit. Another service user spoken with said, ‘my family come to see me, they are made welcome and I can go out with them if I want to.’ Due to the current needs of people living in the home, links with the outside community have lessened over time, however the local vicar and reverend visit the home as well as people who offer entertainment to people should they wish to join in, thus maintaining some contacts. The home is also situated just behind a church and staff stated that should they wish people are assisted to attend the services. Staff spoken with were able to discuss the individual care each person using the service required, they felt that each persons identity and personal needs were catered for when delivering care. They were also able to discuss care that would be offered to cater for diversity of peoples needs should the need arise. Plans of care were individualised and afforded each persons preferences to be acknowledged. One person using the service spoken with said, ‘the staff are very nice, I feel that they know what I like and they treat me in the right way.’ A wholesome and appealing menu is on offer and choices are available at each mealtime. All people using the service spoken with said that they food was at a good standard, plentiful and they had choices if they did not like something. The main lunchtime meal was observed and staff were seen to assist people in an appropriate manner which respected their dignity. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service feel confident that they can approach staff should they have any concerns and that these will be dealt with, however the policy needs to be updated and put on display to aid access should the need arise. People using the service are protected from abuse. EVIDENCE: The service has not received any official complaints since the previous inspection; they have however set up a concerns book, which outlines any small concern that they could deal with, thus preventing the need for a complaint to be made. One complaint in regards to the staffing levels and medication procedures had been referred to the provider from the Commission for Social Care Inspection. There was evidence available to show that these issues had been investigated and were unfounded. The complaints procedure observed was out of date and stated to refer complaints to the National Care Standards Commission, not the Commission for Social Care Inspection, which may cause confusion if this is used. This also is not on display, however the acting manager stated that everyone is told about the complaints procedure when they enter the home. The acting manager maintains an open door policy so people may approach her with any concerns. The relative spoken with said that the manager was very approachable and open and they felt that they could raise any concerns should they arise. All people using the service spoken with spoke very highly of the staff and the care received, no one had any concerns, they did however feel that if they did that they could approach the St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 17 staff and it would be dealt with. Staff spoken with were able to discuss how they would deal with complaints should they be received. Two referrals to the safeguarding adults team have been made in the past year, one in regard to the emergency procedures that staff undertake when a person becomes ill and one in regard to abuse occurring. Both of these were unfounded and closed. Staff spoken with were able to discuss the issues in regards to dealing with challenging behaviour should it occur and the whistle blowing policy should they feel that they need to report poor practice. A number of staff have received training in the protection of vulnerable adults, however there was a deficit in this area, the acting manager showed us evidence to demonstrate that further members of staff had been booked on to several courses to update their training. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the environment is generally satisfactorily maintained the bedroom furniture detracts from this and gives the impression of a ‘shabby’ appearance. EVIDENCE: To ensure that people live in a satisfactory maintained environment an ongoing maintenance programme is in place. The downstairs of the building has recently been redecorated and new carpets laid. During the brief tour of the home all areas were observed to be clean, tidy and satisfactorily maintained with the exception of the bedroom furniture. Although the unsafe bits of wood have been removed from the bedroom furniture, this remains well worn and looks ‘shabby’, which detracts from the comfort of people using the service. The garden path has been levelled to ensure that people using the service can access the garden safely. People using the service said that they felt that the home was clean and comfortable. One relative spoken with said that it was much better now as St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 19 people were able to personalise their own rooms and have their own bed linen in place which made it feel more homely. One person using the service said that they could of brought their own things into the home, however they decided not to. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People needs are met by sufficient numbers of staff. Further attention is needed to ensure that all members of staff have completed compulsory training to ensure that they are fully able to meet service users needs. EVIDENCE: The staff duty rota was seen which showed that sufficient staff are available to meet service users needs. Two members of staff spoken with confirmed that the staffing levels were good at present however they had been short on occasion previously due to sickness. The duty rotas observed showed where shifts had been covered when possible when sickness had occurred. All the people using the service spoken with also felt that sufficient staff were available to meet their needs and they offered the following comments, ‘the staff are very nice and they help me when I need it,’ I am generally independent, however I am sure that the staff would hep me if I needed it,’ and ‘the staff help me to get changed when I need it, they are always available.’ To ensure that all new staff are aware of their roles and responsibilities they undergo an induction on commencing employment. There was evidence of staff undertaking an induction within staff personal files observed. One member of staff spoken with confirmed that they had undertaken an induction and they felt that the staff team had been very welcoming and the induction had been St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 21 helpful. To ensure that staff members have the necessary skills and knowledge to meet the needs of people using the service all except one have completed the National Vocational Qualification level 2 (a nationally recognised work and theory based qualification) and there are plans for more staff to take the higher level 3. One member of staff spoken with confirmed that they had undertaken this training and that they had found it very useful in meeting the needs of people using the service. To establish that people using the service are protected from unsuitable people being employed, four staff files were observed to see if they contained all the necessary documentation required by law. All with the exception of one file contained all the required documentation. One file did not contain two written references, as the staff member had been employed for over five years, the acting manager stated that she would complete a character reference in this instance. One member of staff was able to explain the recruitment procedure that they had undertaken, which followed good practice. To develop staffs knowledge and skills to enable them to care for people using the service they undergo compulsory training. There was evidence of some training taking place within staff personal files, however there were deficits in the following areas; manual handling, dementia care, first aid, the protection of vulnerable adults and food hygiene. Staff spoken with stated that they felt that the training offered was at a good standard and that enough training had been offered. One member stated that they had undertaken training before they had been employed and this was still in date so they had not had that much training whilst in this employment. They were able to discuss relevant issues regarding the care of people using the service and how they would deal with any untoward incidents such as a person becoming unwell and needing emergency care. Staff now undertake supervision sessions with the acting manager, where time is spent discussing their training and development needs and aspects of their job role. Both staff members spoken with confirmed that these take place and that they felt that these were beneficial. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a person who is fit to be in charge. Further developments of the quality audit system would prove beneficial to the people using the service, enabling them to have more input into the running of the home. EVIDENCE: The acting manager has attended an interview with the Commission for Social Care Inspection and has now been deemed fit to manage the care home since this visit. She has previous experience in running and managing a home and remains up to date with her training and development. Staff spoken with said that many changes have taken place and the acting manager was approachable. All people using the service spoken with and the relative spoken with spoke highly of the acting manager and stated that she was open to new ideas and carried things through. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 23 The acting manager stated that informal quality assurance and regular audits of the environment and administration takes place, however there was no documentary evidence available to confirm this. Staff meetings have commenced and there were minutes of the meetings to confirm that these had taken place. One member of staff spoken with confirmed that they had attended a staff meeting and quality issues had been discussed. The acting manager said that she had attempted to hold meetings with the people who use the service and their relatives, however these had so far proved unsuccessful. A number of surveys had been sent to relatives, one relative spoken with confirmed this, however none have yet been returned. Four peoples personal allowances were checked, these corresponded with the accounting sheets and receipts were available for all transaction, demonstrating that people’s money is protected. People may access this money at any time and one person was seen to do so during the visit. The cook is responsible for one service users personal allowance, although this is not advisable it was felt that there was no one else able to act on their behalf, this was documented in the persons plan of care. To demonstrate that necessary servicing of equipment takes place the lift, hoist and gas certificate were observed, all had been tested as required. The fire alarm testing and emergency lights testing had been carried out on a weekly basis, however when the acting manager had been away on holiday this had not been completed. Accident records were observed and contained all the required information. St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 24 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 2 8 3 9 2 10 3 11 X 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 X 18 3 2 X X X X X X 3 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 3 X 2 X 3 X X 2 St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 25 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 12(1,a) Requirement Issues of consent where people using the service are sat in the smoking area must explored and documented to ensure that people’s rights are not infringed upon. Risk assessments in regards to entrapment and the safe use of bedrails and safe smoking arrangements must be developed to ensure that people using the service are fully protected. Handwritten entries on medication records must be signed as correct by two members of staff to avoid errors in administration. Timescale for action 05/05/08 2 OP7 13(7) 05/05/08 3. OP9 13(2) 05/05/08 4 OP16 22(7) 5 OP16 22(5) The complaints procedure must 05/05/08 be updated to contain the correct details of the Commission for Social Care Inspection to ensure that people using the service know who to contact should the need arise. A written copy of the complaints 05/05/08 procedure is to be supplied to every person using the service DS0000002217.V359887.R01.S.doc Version 5.2 Page 26 St Martins Care Home 6 OP19 16(c) 23(2,c) 8 OP30 18(1,c,i) 9 OP33 24(1) (a)(b) and to any other person acting on behalf of a person using the service if that person so requests. Where bedroom furniture is 07/08/08 shabby and broken it must be replaced to ensure that adequate and functioning furniture is available for people who use the service. Evidence is required to 07/08/08 demonstrate that all staff have achieved training in the compulsory areas to ensure that they can fully meet the needs of people using the service. Evidence that the quality 05/06/08 systems in use monitor and improve the service and take into consideration the views of people using the service is required to demonstrate that the service is run in the best interest of people who use the service. 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 To ensure that medicines are kept at the recommended temperature, the room temperature where these are stored should be monitored so relevant action can be taken if necessary. Where tasks such as fire alarm and emergency light testing are to be performed on a regular basis a person should be delegated to carry these out in the manager’s absence. Good practice guidelines on environments for people with dementia care could be followed to improve the environment for the people who live there. 2 OP38 3 OP19 St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 27 St Martins Care Home DS0000002217.V359887.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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