Inspection on 03/02/08 for St Martins Care Home for the Elderly

This inspection was carried out on 3rd February 2008.

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

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

Other inspections for this house

St Martins Care Home for the... 21/08/07

St Martins Care Home for the... 15/02/07

St Martins Care Home for the... 22/05/06

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

CARE HOMES FOR OLDER PEOPLE St Martins Care Home for the Elderly 22 Feckenham Road Headless Cross Redditch Worcestershire B97 5AR Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 3rd February 2008 09:45 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 for the Elderly DS0000065811.V356719.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 for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Care Home for the Elderly Address 22 Feckenham Road Headless Cross Redditch Worcestershire B97 5AR 01527 544592 F/P 01527 544592 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) St Martins Care Home for the Elderly Ltd vacant post Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (12) St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation (without nursing) for service users of both sexes whose primary care needs on admission to the home are within the following categories: - old age, not falling within any other category (OP 12) - dementia over 65 years of age (DE(E) 12) - physical disability over 65 years of age (PD(E) 12) The maximum number of service users to be accommodated is 12. 2. Date of last inspection 21st August 2007 Brief Description of the Service: St Martins is situated in a residential area close to local shops and other amenities. There are limited car parking facilities at the front of the premises and an enclosed garden at the rear. At the time of the inspection an extension was under construction in the rear garden. This extension will provide an additional three single bedrooms with en-suite. The home is currently registered as a care home to provide personal care for a maximum of twelve older people over the age of 65 years. The home is also registered to provide care for older people who may have a physical disability and/or a dementia illness. The people who use the service are accommodated on the ground floor and first floor of the building in eight single bedrooms and two double bedrooms. Two of the single bedrooms have en suite facilities. The home has a stair lift to assist people gain access to the first floor. The communal space consists of a dining room, a front lounge and a smaller rear dining room. The revised draft Statement of Purpose provides information regarding the current range of fees charged. For the most up to date information the reader should contact the service directly. St Martins Care Home for the Elderly DS0000065811.V356719.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 one star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out without any prior notice. One Regulation Inspector visited the home on two separate occasions; the first visit was carried out on a Sunday. The manager designate was present during the second visit to the home. Although not present during the first visit we did have a brief discussion with the manager designate on the telephone. The registered provider was present during the second visit to the home. This inspection takes into account information we have received since the last inspection as well as the visits to the home. During the inspection discussions were held with the manager designate, a number of staff members and people using the service. We had a look around the home and observed what was happening. In addition we viewed the care documents regarding some people using the service such as care plans, risk assessments and daily records. In addition we viewed medication records, staff training records and recruitment records. What the service does well: The manager designate is aware that a needs assessment must be carried out prior to an admission into the home. In addition the manager designate is also aware that the full care needs of an individual need to be established and agreed prior to the admission. The manager designate is aware of the importance of having person centred information available to carers to assist in the care delivery to people with a dementia type illness. The management and recording of medication is generally to a good standard. Care staff make good effort to provide a range of activities for people using the service. The quality of the food provided is good. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A revised and up to date Statement of Purpose needs to be available within the home. A revised Service Users Guide needs to be readily available for people who currently use the service and for people who may potentially use the service in the future. Care documentation continues to fall short of the required standard in that it fails to identify care needs and fails to give sufficient or suitable strategies to address the need. A medication policy needs to be devised in line with practices within the home. The storage facilities available in the event of the home having controlled drugs are not satisfactory and need to be improved. Some concerns remain regarding the level of staffing on at certain parts of the day. Carers are required to prepare afternoon tea, which causes a number of health and safety concerns and needs urgent review to safeguard people using the service. Shortfalls were identified in the training undertaken by some members of staff in areas such as moving and handling, fire safety and safeguarding (adult abuse). St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. St Martins Care Home for the Elderly DS0000065811.V356719.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 for the Elderly DS0000065811.V356719.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): Standards 1 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. Prospective people to use the service and their representatives do not have readily available to them information about the home to assess them making a decision. People can visit the home prior to admission and an assessment of care need is carried out, this assessment needs to be robust and needs to involve all interested people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the previous inspection the manager designate supplied us with a copy of both the Statement of Purpose and the Service Users Guide. Although these documents contained some up dated details other necessary information was not included. One carer believed that Service Uses Guides were available within bedrooms but one could not be located in a randomly selected room. The manager designate stated that she and the registered provider were St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 10 waiting to discuss the users guide with us prior to distributing a copy to people using the service. The information required within these documents is available within the National Minimum Standards and the associated Regulations. It is essential that these documents are in place and that information regarding the service provided is available both to people who may potentially use the service and people who are currently using the service. We were informed that since the previous inspection no new long stay admissions have been made into St Martins care home. However since the last inspection at least one person has been admitted into the home on a short stay (respite) basis. It was evident that visits to the home took place involving both the individual and her family prior to the admission. During these visits information was obtained and an assessment was carried out to establish whether care needs could be met. Following the admission further information became apparent which was previously unknown by staff within the home which made the placement difficult. The experience demonstrates that it is important to establish both the facts and full care needs prior to an admission especially when an independent advocate, such as a social worker, is not involved. Intermediate care is not provided at St Martins and no plans exist to provide this service in the future. St Martins Care Home for the Elderly DS0000065811.V356719.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate The care needs of people using the service are not set out fully in the care plans; therefore carers have insufficient guidance and instructions to deliver consistent care. The management of medication has improved although a written procedure specific to the service needs to be provided to ensure staff are aware of good practice principles. The principles of respect, dignity and privacy need to be put into practice at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care plans are in place regarding each person who resides in the care home. As part of this inspection a small sample of these care plans and other care documents were viewed and assessed. We previously stated that it was encouraging to see information regarding individual’s life history within the care plan. It was acknowledged that having St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 12 this information available could assist staff in providing person centred care to people with a dementia type illness. Progress in developing this information needs to be maintained. The care plans consisted of monthly assessments of the previous months assessment. Due to how the documents were structure some of the information was scant in detail and would not provide the necessary level of information needed to enable staff to provide a consistent care package. Some information was not captured on the necessary care plan, such as issues highlighted by or brought to the attention of the chiropodist. It was however evident that professionals such as GP’s, community nurses and chiropodists are consulted. The cook was aware of some instructions given by a community nurse in relation to the availability of fruit juice. We were concerned to note that the daily notes made regular reference to one person having cream applied. Although this was a regular treatment we found no evidence of a care plan in order to establish the care need, how it was to be managed, when the plan was going to be evaluated and who was going to ensure the need was met and the situation was improving. The cream in use was not recorded on the Medication Administration Record (MAR) sheet and therefore it could not be establish who had prescribed the original treatment. As part of this inspection we assessed the management of medication. The medication procedure was generic and commercially produced and therefore not specific to St Martins. This was highlighted in our previous inspection report. The medication trolley was secured to the wall and good procedures were in place regarding the handing over of the keys. The current months MAR sheets were viewed. The signing of these sheets to confirm that medication was given was in good order. Medication was signed into the home appropriately. When people were on a variable dose the actual dose given was recorded as necessary. A number of audits of medication were carried out, all but one of these balanced correctly. We observed a member of staff undertaking a medication round within the lounge. This was carried out correctly. At the time of the inspection no controlled medication was in use. The CDR (Controlled Drugs Register) was viewed and it was discovered that some medication not signed out of the home at the time of the last inspection was now corrected. In the event of somebody requiring controlled medication in the future the storage arrangements within St Martins are not ideal and need to be reviewed. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 13 People using the service all appeared suitably cared for and were appropriately dressed taking into account the time of year and gender. One carer was heard making an inappropriate comment when escorting a person using the service to the toilet in relation to continence care needs. Staff need to be mindful of making such comments and need to be mindful of the need to respect and uphold the dignity and privacy of people who in the service. St Martins Care Home for the Elderly DS0000065811.V356719.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good The social needs of people using the service are identified and various recreational opportunities are provided to ensure interests are fulfilled. People are offered nutritious and balanced meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Martins is situated close to a number of local amenities meaning that community links are possible. Although no dedicated activities coordinator is employed it was evident that carers make effort to provide activities whenever when they can. The activities can be a one to one session or in a group session. Activities provided include the following: bingo, cards, hairdressing, creative mobility or watching a video or television programme. Plans were in hand for a St Valentines party and pancake day. We received positive comments regarding the care provided at St Martins during our previous inspection by means of surveys sent out. We did not St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 15 survey people prior to this inspection and we did not see any visitors to consult their points of view. Although we did not see any visitors we are not aware of any restrictions on visiting people using the service. People using the service were complimentary regarding the food provided. On the first day of this inspection the main mid day meal was roast lamb, roast potatoes, boiled potatoes, carrots, cauliflower, broccoli and Yorkshire pudding. The meal was served from the kitchen hatch. The meal was plated attractively and seemed to be plentiful. Staff were knowledgeable about the dietary preferences of people for whom they were caring. Breakfast consists of cereals and toast. Boiled eggs are available but cooked breakfasts are not provided. For tea people have a choice between sandwiches and a hot choice such as soup, beans on toast or pizza. St Martins Care Home for the Elderly DS0000065811.V356719.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): Standards 16 and 17 Quality in this outcome area is adequate The complaints procedure needs to be more readily available to people using the service and procedures regarding the safeguarding of people need to be made more local and service specific. Some staff have undertaken training in safeguarding. This training needs to be made available to all staff to ensure everybody has the necessary knowledge needed to recognise potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure held within the previous Statement of Purpose and the Service Users Guide was satisfactory and made reference to a local office of the Commission for Social Care Inspection. This needs to be amended to reflect the recent change in address of the CSCI. The procedure was on display within the home. The complaints log was seen as part of this inspection. The log did not contain any new entries. A previous report noted that an earlier complaint was not recorded within the complaints log. It was noted that this information remains unrecorded. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 17 Nobody living within the home raised any concerns about their ability to complain during the course of this inspection. We have received no concerns or complaints regarding the service provided at St Martins since our last inspection. We have previously commented on the need for the policy and procedure on safeguarding (adult protection) to include local information, as the one held was a commercially produced one. This remains to be the case. Some information regarding Worcestershire Adult Services procedures on safeguarding was available such as a poster and leaflets for staff. No incidents, which need to be recorded as safeguarding, have been brought to the attention of the manager designate and no such incidents have been reported to us. Training records showed that a number of staff received training in relation to safeguarding during July 2007. A number of staff need to undertake this training. St Martins Care Home for the Elderly DS0000065811.V356719.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): Standards 19 and 26 Quality in this outcome area is adequate Building work continues outside of the home, which needs to be continual monitored to ensure the home is safe. The environment currently in use is sufficiently comfortable to ensure that people using the service have a homely place in which to reside. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Martins care home is located in a mainly residential area near to shops and other amenities such as a public house. The home is accessible to people in a wheelchair as a ramp is provided however corridor areas within the home itself are narrow. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 19 The home does not have a passenger lift however a stair lift is provided to enable access to the first floor. The home was found to be comfortable and homely. The décor within communal areas is adequate. Within our last inspection report we highlighted the fact that the upstairs bathroom floor is carpeted. We previously stated that having this area carpeted could be a concern regarding the ability to keep it hygienically clean. This carpet remains in place. The stair carpet continues to show signs of wear and tear and needs to be closely monitored to ensure that it does not present a health and safety risk. Radiators throughout the home were covered to prevent accidental scalding with the exception of one in the upstairs bathroom. The fact that this radiator is uncovered was highlighted within our last report. The risks associated with having an uncovered radiator must be fully assessed and suitable action must be taken. Bedroom accommodation consists of eight single bedrooms and two doubles. There is no programme of refurbishment although bedrooms were well maintained. People using the service are able to personalise their bedrooms. Two bedrooms have en-suite facilities. The décor in the bedrooms viewed was satisfactory. The lighting in bedrooms was also satisfactory although the use of energy saving bulbs made the lighting dim at first. On trying the hot water in one bedroom the supply was found to be slow. Work is currently underway to provide an additional three bedrooms in a ground floor extension. The registered provider is aware that an application must be made to us and approved before these rooms can be used. Due to the building work the back garden is currently untidy and could be a health and safety concern were people using the service to gain access to it. During the previous inspection a washing machine with a sluice facility was being fitted and the registered provider was making good the flooring. The flooring in this area is now in good order and a wash hand basin is now in place. Cleaning items are stored in a cupboard within the laundry. Upon our arrival on the first day of this inspection the pad lock was not in place on the cleaning cupboard therefore making the contents unsecured. The detergent used within the washing machine was left open therefore exposed and potentially accessible to people using the service. The pad lock was later found and a member of staff informed us that they had put it on for us. No unpleasant odours were detected at any time within the home. St Martins Care Home for the Elderly DS0000065811.V356719.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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate Improvements have taken place in the provision of training and these need to continue to ensure that staff delivering care to people have the necessary skills and knowledge. Staffing levels at certain times of the day continue to be minimal. People using the service are protected by the recruitment and selection procedures that are followed by the manager designate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Over recent inspections we have reported a number of changes regarding the person employed as manager. The current manager designate was in place at the time of our previous inspection. It was confirmed that the manager designate is now provided with additional ‘management hours’ therefore reducing the time spent working as a carer. The deputy manager who works as part of the care team covers day shifts. It was reported that during the morning shift two carers are on duty. For a couple of hours during the afternoon it was stated that one carer and the manager designate are on duty together. Two carers cover the evening shift while one wakeful carer and one carer sleeping in cover the night shift. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 21 A housekeeper works four days per week. Carers have to perform domestic duties on the remaining days (Tuesday, Saturday and Sunday). Nobody is employed within the laundry therefore carers have to undertake this duty. Catering staff are employed each morning although carers have to undertake the final preparation of tea. This continues to be a concern due to the reduction of staff available to provide care to people living within the home as well as the risk of cross infection. We were informed that everybody holds a basic food hygiene certificate. Staffing levels within St Martins need to be reviewed to ensure that the identified care needs of people using the service can be met. The current extension to the home will entail additional persons living within the home therefore again raising the need to increase staffing levels. No agency staff are used within the home and no relief care staff are employed. We have previously noted that the majority of staff have undertaken training covering a range of areas. We previously highlighted some shortfalls regarding training in matters relating to health and safety. Training is booked for health and safety, fire safety, first aid and moving and handling. One member of staff identified had not received essential training other than some input during induction. The manager designate continues to be aware of the shortfalls and intends to deal with the situation. Progress in training including induction will be assessed at the next inspection. The number of staff who hold a National Vocational Qualification remains the same as at the time of our previous inspection. During this visit we were told that four carers hold a level 2 qualification. The deputy manager holds a level 4 NVQ in care. As a total of ten carers plus the deputy are currently employed within the home the percentage of qualified staff fails below the 50 level needed to meet the National Minimum Standard. The home has a recruitment procedure that meets the regulations and the National Minimum Standards. The procedure is followed in practice and there is suitable recording and records held such as references and CRB’s (Criminal Record Bureau) and PoVA (Protection of Vulnerable Adults) checks regarding new employees. St Martins Care Home for the Elderly DS0000065811.V356719.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): Standards 31, 33, 34, 35, 36 and 38 Quality in this outcome area is adequate The provider’s delay in funding the application to register the manager is of concern and demonstrates a lack of willingness to abide by regulatory requirements. The introduction of a quality assurance system and formal staff supervision help to ensure that the home is run in the best interests of people using the service. The health, safety and welfare of people are generally promoted in respect of safe working practices, although some areas need to be developed or improved to ensure that people are fully protected. This judgement has been made using available evidence including a visit to this service. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager designate was appointed in July 2007. Our previous report (August / September 2007) stated ‘At the time of this inspection the newly appointed manager designate had not applied to us to become the registered manager. This application must be made without any undue delay.’ A requirement was made within that report for the application to be made with a timescale of before the end of October 2007. At the time of this inspection no application had been made. This was discussed with the registered provider who undertook to ensure the application is now made. The manager designate reported that she has completed the RMA (Registered Managers Award) and has commenced upon the NVQ (National Vocational Qualification) level 4 in care. Since the previous inspection a quality assurance (QA) system has been introduced. The progress in monitoring and reviewing the service will be assessed as part of future inspections. During this visit we saw some questionnaires recently returned to the home from relatives. One questionnaire stated ‘ We are very satisfied with St Martins’ 09/01/08. The service offers the facility whereby people using the service can have a small amount of money held in safekeeping. We checked the records and balances of a random number of people and found them to be in order. A new certificate of public liability was available during the inspection as the previous one had expired on the 29th January 2008. Staff supervision has improved since the last inspection. All carers received a supervision session between September and December 2007 and most had received another during January 2008. Supervision does need to improve further in order to meet the National Minimum Standard but the progress made is noted. The previous report stated ‘ The hoisting devise within the bathroom had not been serviced as required under The Lifting Operations and Lifting Equipment Regulations 1998’. During this inspection we saw evidence that this piece of equipment was serviced during October 2007. It was not however evident that the servicing included load lifting as well as electrical safety. The stair lift was serviced during November 2007. The registered person is therefore reminded of the comment within the previous report and of the fact that this service is required every six months for all pieces of equipment that lift people. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 24 Since the last inspection the manager designate has made reciprocal arrangements with another nearby care home regarding offering a place of safety in the event of a major emergency such as fire or flood. Contingency arrangements are also in place regarding the transporting of people to this place of safety. The manager designate should be commended for making this arrangements and having the information freely available for staff to refer to. Our previous report commented on the fact that the fire risk assessment made a number of recommendations some of which remained outstanding and in need of action. The assessment stated: ‘In order to ensure fire safety and health and safety of all persons in the premises all wedges should be withdrawn and replaced with approved hold open devices connected to the fire alarm system or (named type of device). During the previous inspection we found that a number of doors had one of the named devices fitted, however at that time some wedges were in place. Although further devices are now in place we still found evidence that doors are wedged open including the laundry door. As laundry areas can potential be considered a higher risk area this door needs to be kept shut at all times or a suitable devise needs to be fitted to ensure the door would shut upon activation of the fire alarm. Other wedges were seen in bedrooms and along a corridor. The fire log showed that the fire alarm is regularly tested; however the use of correction fluid on these records should not happen. It was of concern to see some on going recording of a fire door not closing. We were informed that a new bell was fitted in order to active the above devises. Other fire records need to be updated to show the work, which was reported to of happened in relation to emergency lighting. No fire training was recorded within the fire log since March 2007. The fire extinguishers were serviced during January 2008. We brought to the provider’s attention that the dial on one extinguisher was closed to the red zone showing that it may need re-charging. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 25 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement A comprehensive care plan must be in place in relation to each person using the service in order that health and welfare needs can be identified and met. Timescale for action 31/05/08 2. OP31 8,9 The acting manager must make 31/03/08 an application to the CSCI for registration. Having a registered manager will assist in ensuring that regulations are met and care needs addressed. The previous timescale of 30/10/07 was not met. This must now be actioned. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be revised. The users guide should be available to all current and potential users and should contain all the necessary information including areas previously recommended in our reports A policy and procedure for the receipt, recording, storage, handling, safe administration and disposal of medication specific to St Martins should be drawn up and implemented. Suitable facilities for the safe storage of controlled medication should be provided. 2. OP9 3. OP9 4. OP18 The home’s policy and procedures for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) should be amended in accordance with the Public Interest Disclosure Act 1998, the Department of Health guidance ‘No Secrets’ and the guidance in this report. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be introduced and implemented with records kept. All of the staff should be issued with a copy of their terms and conditions of employment (contract). 5. OP19 6. OP29 7. OP36 Care staff should receive supervision at least six times a year. St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI St Martins Care Home for the Elderly DS0000065811.V356719.R01.S.doc Version 5.2 Page 29 - 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. 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