Inspection on 12/06/07 for St Martins Haven

This inspection was carried out on 12th June 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Martins Haven 04/10/06

St Martins Haven 09/02/06

St Martins Haven 22/09/05

St Martins Haven 23/12/04

St Martins Haven 09/06/04

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Townley Road, 2-3

Foxley Lane (121a)

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Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 St Martins Haven 86 Culverley Road Catford London SE6 2JY Lead Inspector Lisa Wilde Unannounced Inspection 20 June & 9 July June 2007 2:00 th th St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 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 Haven DS0000025644.V343185.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 Adults 18-65. 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 Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Haven Address 86 Culverley Road Catford London SE6 2JY 0208 465 0020 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) Elizabeth Peters Care Homes Limited Jayne Bird Care Home 6 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (6), Mental disorder, excluding learning of places disability or dementia (6), Mental Disorder, excluding learning disability or dementia - over 65 years of age (6) St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 6 persons with dementia or mental health problems over 50 years 4th October 2006 Date of last inspection Brief Description of the Service: St Martins Haven is a small care home in a quiet residential street in Catford. The home provides care for six adults with past or present mental health problems who are aged 50 and above. The home is a good walk away from the town centre, although there is a parade of shops much closer. Public transport is available in the form of local buses and two train stations, both of which provide links into London. The home is one of a group of homes run by Elizabeth Peters Care Homes Limited. There were no vacancies on the day of the inspection. The range of fees for a place at the home was not available at the time of writing the draft report. The home makes the reports of the Commission’s inspections available to residents in the hallway of the home. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2007 with the inspector waiting for written information to be sent on afterwards. The inspector met with residents, staff and the Registered Manager. The inspector toured the building, checked records and examined the medication stocks. All residents said they were happy, had no problems and liked the staff. The inspector found again that this home provides a high standard of care to residents and very few problems were found during this inspection. What the service does well: Some things at this home are good. • • • • • • • • • • • • • Staff make sure that they can help service users before they come to live there. Staff write down what they will do to help service users. Staff make sure that service users are kept safe. Staff help service users go out when they want to. Service users choose what they want to eat and staff cook for them. Staff make sure service users go the doctors when they need to. Staff make sure service users take their medication properly. Service users know how to complain. The home is comfortable and clean. Service users have their own rooms. Staff have the right qualifications. Staff get regular help from the manager. The manager can run the home well. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet the needs of residents before they are offered a place at the home. EVIDENCE: Most of the residents have been at this home for a long time and no service users have moved to the home for a few years but this standard was assessed as met at a previous inspection. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff write care plans that describe what they will do to make sure that all residents’ needs are met. Not all elements of the care plans are reviewed often enough which means that residents may not have their changing needs met. Risks are assessed and plans put in place to make sure that any risk is managed which means that residents are kept safe. EVIDENCE: Care plans are in place around all areas of residents needs that are reviewed regularly by the Registered Manager. Some of the residents at the home are over 65 and as such they must receive the same care as they would if they were in a home specifically for older people. This means that all elements of their care plans must be reviewed every month. (See Requirement 1) St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 10 There was a previous requirement that the Registered Manager must ensure that records are kept of when service user annual reviews take place and if she believes that she will not receive the minutes for several months, that she takes her own minutes. This is now done. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported to do what they want to do and go out when they want to. Residents choose what they want to eat and staff cook for them. EVIDENCE: The residents spoken to told the inspector that they were happy at the home and they got to do everything they wanted to do. Staff cook for residents and records are kept of what they eat each day. Residents said that they liked the food a lot and they get to eat what they want. The menus are varied but perhaps not quite as healthy as they could be. (See Recommendation 1) St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff support residents in different ways and service users are encouraged to attend regular appointments to make sure they stay healthy. Medication systems are generally operated effectively so residents know they are getting their medication as they are supposed to. EVIDENCE: Health and personal care records showed that residents are supported to keep appointments and look after themselves. There was a previous requirement that the Registered Manager must ensure that the medication stock checking systems are effective. This is now effective. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents know how to complain and their day-to-day concerns are taken seriously and action is taken to make things better for them. Residents are protected from harm by staff receiving training and understanding what to do if they think a resident is being abused. EVIDENCE: There is a complaints procedure although there have been no formal complaints since the last inspection. The home keeps records of informal concerns and what is done to address these concerns. There was a previous requirement that the Registered Individuals must ensure that the policy on restraint includes statements about how staff should not attempt to restrain a service user at this home, given that this is the stated practice of the home. This has been done. Staff are trained in safeguarding adults issues and the home has a copy of the borough’s up-to-date procedures. The Registered Manager was aware of the new Mental Capacity Act and its effect on assessing resident’s capacity to make decisions but there is not yet an organisational procedure or programme of staff training. (See Requirement 2) St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely throughout. Residents have their own rooms that they have decorated how they choose and the communal areas are large enough. EVIDENCE: On the day of the inspection the home was clean and hygienic throughout. All residents have their own rooms that they can decorate how they choose. All residents spoken to said they liked their rooms and had everything they needed. There is a large lounge and a separate dining room. The garden is at the back of the home and is well kept. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the needs of residents and they hold the right qualifications and get enough training which means that residents are cared for by people who know what they are doing. Recruitment procedures are now effective enough which means that the organisation is doing enough to check up on the people who work in the home and to make sure that it is employing staff who can do the job. Staff receive regular supervision from the manager and an annual appraisal of their work performance which means that residents are offered care from staff who are receiving enough advice and support. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that they are clear about how many senior support workers are required at the home (two or three) and that arrangements are made to recruit to the post that is currently being filled by an acting up support worker or if that third St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 16 senior post is deemed unnecessary, the support worker returns to their substantive post. All staff hold the NVQ Level 2 in Care. There were several previous requirements about the recruitment procedures all of which were met by this inspection although no reference had been gained from the most recent employer and there was no explanation in the recruitment pack as to why. (See Requirement 3) There was a previous requirement that the Registered Individuals must ensure that the induction and foundation programme being used is the most up-todate version of the Skills For Care (and not TOPSS) programme. This is now in place. There was a previous requirement that the Registered Individual must ensure that all staff have an individual training programme in place drawn up following an at least annual appraisal and that these plans are then brought together into an overall annual training plan for the home. This is now being done. There was a previous requirement that the Registered Individual must ensure that the Registered Manager receives regular supervision, an at least annual appraisal of their work performance and training and that an individual training plan is drawn up for them. This is now done. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Registered Manager has been at the home for several years and holds or is undertaking the required qualifications, which means that she has the skills to run the home well. There is now a thorough system that looks at developing the home and planning to make things better for residents each year. Residents are protected from harm by the effective operation of all health and safety procedures. EVIDENCE: St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 18 There was a previous requirement that the Registered Individuals must ensure that there is a forward looking quality assurance system in place in the home that is based on the views of residents and which focuses on a process of continuous improvement. There has been a lot of work over the past year on drawing up a quality assurance programme for the home that covers all the areas of the service. It now meets the standard although it hasn’t yet been fully used and the information is still as it was last year, although work is being done to collate and start to transfer the information. There was a previous requirement that the Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. These are being done and now no longer need to be sent through to the Commission each month but they are not being kept at the home. (See Requirement 4) All health and safety documentation and checks were in place and in order. There were no health and safety problems noted on the tour of the building. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 20 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 YA6 Regulation 15 (2) (b) Requirement The Registered Manager must ensure that all care plans for service users who are over 65 years of age are reviewed monthly. Previous requirement: Unmet timescale 31/10/06 The Registered Individuals must ensure that an appropriate policy and procedure is drawn up regarding the mental capacity act, that staff are aware of the effect of this and that effective assessments of capacity are conducted when necessary. The Registered Individuals must ensure that a reference is gained from the most recent employer where possible or an explanation as to why this is not done is kept on file. The Registered Individual must keep records in the home of the monthly unannounced visits. Timescale for action 30/08/07 2. YA23 18 (1) (c) (i) 30/09/07 3. YA34 19 (1) & (4) 31/08/07 4. YA39 26 (3) 31/07/07 St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 21 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 OP15 Good Practice Recommendations The Registered Manager should ensure that staff think about creative ways to introduce more fruit and vegetables into meals. St Martins Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Haven DS0000025644.V343185.R01.S.doc Version 5.2 Page 23 - 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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