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Inspection on 15/08/06 for St Martins Residential Home

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

This inspection was carried out on 15th August 2006.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

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

St Martin`s provides care in a relaxed atmosphere for people with mental health problems. Most residents say that they enjoy the food and all appreciated the easygoing relationship which they have with the staff. Nearly 50% of care staff have an NVQ2 and several others are due to complete the qualification shortly. The administration of medication is properly organised and recorded.

What has improved since the last inspection?

The Registered Manager has continued to develop care planning. There has been some redecoration and recarpeting since the last inspection. Staff receive regular supervision. The rockery in the back garden has been improved and redesigned. The home is now employing a dedicated cook and residents said that they enjoy the new menus and home cooking. The home has held interviews for the post of Activities Organiser and an appointment is imminent.

What the care home could do better:

Several staff were working at the home without having received POVA clearance or references. This is unacceptable, a breach of the Care Standards Regulations 2000 and potentially puts residents at risk. This must be resolved as soon as possible and must not be repeated. Some furniture and carpets need to be replaced. Accessible care plans are not yet in place but there are plans to introduce a new, computer based system of care planningdocumentation. The Communications Book is being used to convey confidential information. The home does not yet have a quality assurance system.

CARE HOME ADULTS 18-65 St Martins Residential Home 63 Martins Lane Wallasey Wirral CH44 1BG Lead Inspector Peter Cresswell Key Unannounced Inspection 15th August 2006 08:45 St Martins Residential Home DS0000018941.V294093.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 Residential Home DS0000018941.V294093.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 Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Residential Home Address 63 Martins Lane Wallasey Wirral CH44 1BG 0151 639 9877 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) Assistwide Limited Mr David Swift Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) named female service user aged over 65 years (MD/E) within an overall total of 16 MD 27th February 2006 Date of last inspection Brief Description of the Service: St Martins Residential Home is situated in a residential area of Wallasey, close to Liscard Village. It is a substantial detached property with two floors and a number of internal changes of level. The home would not be suitable for an independent wheelchair user or anyone with a physical disability. St Martins is not externally identified as a care home and blends in with the surrounding buildings. There are twelve single bedrooms and two that can be shared if residents so wish. The home has a dining room, lounge, and a spacious conservatory which overlooks the large garden and also serves as the smoking room. Shops, a post office, pubs, restaurants, other community facilities and bus routes are available in Liscard Village, only a short walk from St Martins. The Registered Person owns another similar home nearby. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit when the Registered Manager was on holiday. The inspector spoke to most of the residents, the manager of the Registered Person’s other home (who is the Registered Manager’s line manager and, in effect, the group manager) the Registered Person himself and several staff. He toured the home, examined medication administration and a range of documents, including residents’ files, staff recruitment files and fire safety records. The inspector also examined a concern raised by a member of the public. There were no requirements arising from that concern and a response has been sent directly to the person concerned. The Registered Manager returned a Pre Inspection Questionnaire before the site visit. Service user surveys were sent to a number of residents and three were returned. What the service does well: What has improved since the last inspection? What they could do better: Several staff were working at the home without having received POVA clearance or references. This is unacceptable, a breach of the Care Standards Regulations 2000 and potentially puts residents at risk. This must be resolved as soon as possible and must not be repeated. Some furniture and carpets need to be replaced. Accessible care plans are not yet in place but there are plans to introduce a new, computer based system of care planning St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 6 documentation. The Communications Book is being used to convey confidential information. The home does not yet have a quality assurance system. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Martins Residential Home DS0000018941.V294093.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 Residential Home DS0000018941.V294093.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is adequate. Service users do not have up to date information on the home as the service user guide is out of date. The home has pre-admission assessment procedures to ensure that it can meet the needs of the residents who are admitted. EVIDENCE: The home’s service user guide needs to be reviewed to ensure that it is up to date and meets the National Minimum Standards and the Care Homes Regulations 2000. The current guide refers to the ‘National Care Standards Commission’, which was replaced by the Commission for Social Care Inspection in 2005. No new residents have been admitted since the last inspection; assessment documents and procedures are in place and contracts are on file. One resident confirmed in the survey that he ‘had a look around with my CPN and family before accepting offer of a placement’. Another had discussed the matter with her (named) social worker and close relative before being discharged from hospital and moving to St Martins. The home charges the standard fees paid by Wirral Borough Council. St Martins Residential Home DS0000018941.V294093.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10. Quality in this outcome area is adequate. Plans to improve care planning will ensure that staff have appropriate information to hand. Current use of the communication book does not ensure complete confidentiality. EVIDENCE: Care plans were in place on the residents’ files examined but they were not all in a format which could be easily used by staff. The group manager, who manages the Registered Person’s other, nearby home said that in that home he has just introduced a computerised care planning system, called ‘Care Management System’ (CMS). The Registered Person is planning to introduce the same system to St Martins in the next few months. CMS requires a lot of work to input all the information but appears to record it in an easily useable format. It also allows staff to enter daily reports on individual residents. Individual files at St Martins do contain a great deal of information on residents and the new system may allow that to be put into an accessible form which can be readily used on a daily basis by care staff. Daily reports are still very brief and would possibly be improved if care plan summaries were filed alongside the daily reports sheets. At present the communications book, which records handover information, is also used to record information on individual St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 10 service users, including information about medication and personal care. This is not appropriate as the Communications Book does not protect confidentiality or allow the entries to be filed on the service user’s personal file and therefore inform future decisions. All such entries must be made on the daily reports, which all staff should read when they start their shift. The Communications Book can then be used to signpost staff to individual files. All of the residents go out of the home on their own and with other residents and friends; appropriate risk assessments were in place. The home has a policy on confidentiality which is dealt with during induction training. St Martins Residential Home DS0000018941.V294093.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is adequate. Residents are able to take part in activities of their choice and the imminent appointment of an activities organiser will help to widen their choice. Most residents enjoy the meals in the home and feel that they meet their tastes and dietary needs. EVIDENCE: Some residents attend day centres, where they take part in a range of activities and training. They are offered the opportunity to attend a place of worship if they choose to do so, though none appeared to do so. Most of them receive support from Community Psychiatric Nurses or social workers. Residents take part in various other activities, such as lunch clubs, and the Registered Manager arranges some activities for them. However, most appear to make their own arrangements, going out to shops, cafes and other local facilities. Responding to the residents’ survey, one resident said that ‘staff are also available when I wish to go out accompanied’. The Registered Person’s other home now has a people carrier and it is planned to use that for the residents at St Martin’s as well, though this does seem to have been in the pipeline for some time now. One of the residents has a cat, which sleeps in St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 12 her room. The group manager interviewed for the post of Activities Organiser at St Martins the week before the site visit and was planning to make an appointment that week. The post will be for 20 hours a week and should enable the home to organise more activities, both collectively and individually. Residents sometimes need motivating to take part in activities and this will be part of the role of the new post. Family and friends are free to visit the home at any time of the residents’ choosing and many do so. Residents follow their own routines and have keys to their own rooms. Smoking is restricted to the conservatory, a rule which is understood and accepted by the residents. The Registered Manager has appointed a new cook and the residents spoke highly of the food she prepares. She has, after consultation with the residents, introduced a revised menu for the evening meal. The new menu includes chicken korma and sweet and sour pork. The evening meal is still serves at the rather early hour of 4.30, though none of the residents complained about this. The timing of the evening meal would be a suitable focus for quality assurance. During the site visit several residents visited the kitchen to make snacks or drinks for themselves. Snacks such as biscuits and toast are freely available throughout the day. Staff were seen preparing individual snacks (such as a fried egg sandwich) for residents during the site visit. There are no residents with particular cultural needs in respect of food in the home at the moment but the Registered Manager said that suitable food would be provided as required. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is good. Residents have access to all necessary heath services and medication is well organised, protecting the health and welfare of residents. EVIDENCE: Few of the residents need physical personal support. The Registered Manager is still working on the introduction of a keyworker system. Such a system would help the development of care plans and activities and its introduction is proving to be a rather drawn out affair. The plan is to introduce teams of key workers. Residents receive all of the community and specialist medical support that they need and several have the support of a Community Psychiatric Nurse. None of the residents deal with their own medication and the home uses a system based on NOMAD pre-loaded cassettes. Medication is well organised and securely stored. A special cabinet is available for Controlled Drugs should any be prescribed; those drugs currently stored in it are not in fact Controlled Drugs and should not be kept there should any Controlled Drugs ever be prescribed. The home does not keep homely remedies. Some residents receive medication which is to be administered ‘as required’ (PRN) and a member of staff said that details of what this means in each case are kept on the resident’s own file. Details of any wishes concerning death and dying were seen on the files examined. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. The home has a satisfactory complaints procedure which residents can use to make their views heard, though records of complaints are not yet filed adequately. EVIDENCE: St Martins has a complaints procedure that includes details of how to contact the Commission for Social Care Inspection (though the Complaints section in the service user guide still refers to the now defunct NCSC). Details of complaints are recorded in a complaints book. It would be preferable if , in addition, reports of complaints were kept in a ring binder or similar file in order that the Registered Person can readily comply with Regulation 22(8). The Registered Manager has a copy of the Wirral Adult Protection Procedures and staff receive training in the Protection Of Vulnerable Adults. Staff were unable – for operational reasons - to attend the recent adult protection event organised by Wirral Social Services but the Registered Manager wrote to the organisers asking to be kept informed of future events. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30. Quality in this outcome area is adequate. The home provides reasonably furnished accommodation but some attention is needed to some décor and furnishing in order to fully meet the needs of the residents. EVIDENCE: St Martin’s is in a residential area near Liscard Village where there are shops, a post office and other local facilities for the community. There are some corner shops even nearer to the home. St Martins is inconspicuous, blending in with the other buildings in the area. It has three floors and a number of changes of level. The home does not have a shaft lift and would therefore not be suitable for wheelchair users or anyone who has difficulty negotiating steps. The one resident who is over 65 has a ground floor room and is in any event physically fit. The home has a dining room, TV lounge and conservatory, which is also the smoking area and is therefore very popular, as about two thirds of the residents smoke. During this unannounced inspection the communal areas were very well used, though a number of residents chose to spend time in their rooms and some went out. The lounge has comfortable leather sofas and a television. The conservatory overlooks a large, well-maintained garden. The St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 16 rockery has been redesigned in an imaginative and extremely distinctive way, using blue wood chips. The communal areas were clean and well maintained, though the furniture in the conservatory needs to be replaced if it cannot be satisfactorily cleaned or refurbished. All residents have single bedrooms apart from one couple who share a room by choice. The bedrooms visited were on the whole clean, though one of them, where the resident is reluctant to allow help, needed closer attention. The nature of the bedrooms varied widely, reflecting the personalities of the residents. All of the bedrooms have locks fitted and the security snips have been removed to enable access in an emergency. The doors to rooms 4 and 5 did not close fully into their rebate and were therefore ineffective as fire doors. Alarm call points are fitted in each bedroom. The inspector did not visit all of the bedrooms on this site visit as some residents were out. The home has sufficient bathrooms and toilets. The home has a programme for redecoration and refurbishment but some of the carpets, especially the one in the corridor and steps near room 8, needs to be replaced now. Some of the toilet and bathroom locks have been replaced by suitable ones which can be opened from the outside in an emergency. However the lock to the toilet with a sliding door on the first floor is ineffective as it does not lock the door and the ground floor bathroom lock still needs to be replaced. The vinyl covering to this bathroom was lifting. Some of the bed linen needed to be replaced as it had holes or had worn very thin. As not all of the bedrooms were inspected on this occasion the Registered Manager should check all of the bed linen and replace any that is too old or worn. Residents said that their beds were changed regularly. The headboard in one of the ground floor bedrooms needs to be replaced and the toilet in the bathroom on the first floor mezzanine needed cleaning. None of the residents need any specialist equipment at the moment. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36. Quality in this outcome area is poor. Staff recruitment policies do not ensure the safety of residents. EVIDENCE: There have been several changes in staff recently. Nine care staff are employed, four of whom have NVQ2. Four more are currently studying for NVQ2. The home therefore falls slightly short of the standard of 50 of care staff qualified to NVQ2 but this should be achieved shortly as some staff are near to the end of their course. New staff receive induction training and the home continues to show a commendable commitment to staff training. Recent training has included courses on the Administration of Medication, Food Hygiene, First Aid and Moving and Handling. It would help the Registered Manager to monitor training if he maintained a training matrix setting out which staff have done which courses. The home provides enough care hours, with two care staff on duty at all times as well as domestic staff, a cook and a handyman shared with the nearby sister home. In the survey one resident said ‘staff are always willing to help you whenever possible’. There was no Senior Care Assistant in post at the time of the site visit but the line manager said that he had completed interviews for the post and would be making an appointment in the following few days. Staff have job descriptions but are expected to work flexibly. Until recently this meant that some care St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 18 staff had to do other tasks such as cooking.. Although they do still help with cooking, the home now employs a specialist cook. Several new staff have been recruited since the last inspection and there were no POVA checks or CRB certificates available for two of them. This is a breach of the Care Homes Regulations 2000. The Registered Manager’s line manager said that this had happened for two reasons. First of all he said that the home had been short of staff and needed to appoint people in a hurry; secondly there had been a mistake in the fees paid to the umbrella body. Neither is an acceptable reason for recruiting staff without completing checks that are essential for the protection of residents. Staff must not work at the home under any circumstances before the Registered Person has ensured that they are not on the POVA (Protection Of Vulnerable Adults) register. They must then work under supervision until a satisfactory CRB check is received. No references had been obtained, or even sought, in respect of one of the new starters. Again, this is a requirement of the Care Homes Regulations 2000. (The POVA register lists staff who have been found to be unsuitable to work with vulnerable adults and are legally barred from doing so). In respect of the concern raised by a member of the public the recruitment records of a named individual were checked and were found to be in order. The Registered Manager supervises staff every two months and the supervision sessions are recorded. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is adequate. There is no development plan to improve the home to enhance the residents’ quality of life as the home does not yet have a quality assurance system. The home has appropriate safety policies and procedures to protect residents’ safety. EVIDENCE: The Registered Manager has an NVQ4 and the Registered Manager’s award. He has managed the home for three years and is line-managed and supervised by the manager of the Registered Person’s other nearby home who is in effect the group manager. During the site visit the relationship between staff and residents was relaxed and informal. The inspector spoke to the staff who were on duty and they confirmed that the atmosphere in the home was good. Residents’ survey returns described the manager as ‘helpful’ and ‘always available with support and advice’. St Martins still does not have a quality assurance system, though the views of residents are gathered at meetings. The group manager said that the other home has now obtained the Investors In People award and it was planned for St Martins to do the same. This would St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 20 provide the home with a quality assurance framework but the Registered Manager must make sure that systematic analysis of the views of residents is part of any quality assurance system. The group manager visits the home every day; the Registered Person visits the home more than once a week and prepares reports to meet the requirements of Regulation 26. The kitchen was clean and well organised, with food stocks regularly rotated and checked. Fridge and freezer temperatures were checked and recorded. The small residents’ fridge in the dining room has been repaired. The Registered Person may wish to adopt the Food Standards Agency’s Safer Food, Better Business pack to help manage food safety in the home. Fire safety records and safety certificates were up to date, but some fire doors need to be adjusted to ensure that they close automatically into their rebates. Hot water from some of the taps was excessively hot and the thermostat should be checked. The Employers Liability Insurance Certificate was displayed in the corridor near to the office and was up to date. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 21 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 2 X X 3 X St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 15 Requirement The Registered Person must prepare for each resident a care plan (the ‘service user’s plan’), setting out how their needs are to be met, and must keep the plan under review. Confidential information must not be recorded in the Communications Book. (Original timescale of 24 February 2005 not met.) The Registered Person must provide adequate furniture and bedding and must therefore: *review the quality of bedding and replace any which is inadequate; *replace or repair the chairs and sofas in the conservatory; *replace the carpet in the identified corridor; *properly affix the vinyl flooring in the ground floor bathroom; *replace the headboard in the identified bedroom. The Registered Person must eliminate risks to the safety of residents and must therefore DS0000018941.V294093.R01.S.doc Timescale for action 01/10/06 2. YA26 16(c) 01/10/06 3. YA38 13(4) 01/09/06 St Martins Residential Home Version 5.2 Page 23 ensure that: *the unsuitable locks to the identified toilets are replaced with locks that can be opened from the outside in an emergency; *hot water is delivered at a safe temperature. *all fire doors close fully into their rebate. 4. YA34 19 The Registered Person shall not employ a person to work at the home unless that person is fit to do so and has the information set out in Schedule 2 of the Regulations. The Registered Person must therefore ensure that: *POVA clearance is obtained before any person works in the home; *staff are closely supervised until a valid CRB certificate is obtained; *references are sought. The Registered Person shall establish a system for reviewing the quality of care provided at the home. 15/08/06 5. YA39 24 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA32 Good Practice Recommendations The home needs more staff with at least NVQ2 to meet the standard of 50 of care staff with this qualification. The Registered Manager should keep an up to date record of training undertaken by staff. St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Martins Residential Home DS0000018941.V294093.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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